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HX64074587 
I)      RA644.M2  H67        The  malaria  problem- 


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THE 

MALARIA  PROBLEM  IN 

PEACE  AND  WAR 


BY 
FREDERICK  L.  HOFFMAN,  LL.  D. 

Third  Vice  President  and  Statistician  The  Prudential  Insurance  Company  of  America, 
Chairman  Subcommittee  on  Statistics,  National  Malaria  Committee,  Author 
of  "A  Plea  and  a  Plan  for  the  Eradication  of  Malaria  Through- 
out the  Western  Hemisphere,"  etc. 


A  consolidation  of  papers  read  at  the  Annual  Meeting  of  the 

National  Committee  on  Malaria,  Memphis,  Tenn., 

November  12,  1917,  and  the  Annual  Convention  of  the  New  Jersey 

Mosquito  Eradication  Commission,  Atlantic  City,  N.  J., 

January  31,  1918,  materially 

revised,  enlarged  and  brought  down  to  date 


THE 

MALARIA  PROBLEM  IN 

PEACE  AND  WAR 


BY 
FREDERICK  L.  HOFFIVIAN,  LL.  D. 

Third  Vice  President  and  Statistician  The  Prudential  Insurance  Company  of  America, 
Chairman  Subcommittee  on  Statistics,  National  Malaria  Committee,  Author 
of  "A  Plea  and  a  Plan  for  the  Eradication  of  Malaria  Through- 
out the  Western  Hemisphere,"  etc. 


A  consolidation  of  papers  read  at  the  Annual  Meeting  of  the 

National  Committee  on  Malaria,  Memphis,  Tenn., 

November  12,  1917,  and  the  Annual  Convention  of  the  New  Jersey 

Mosquito  Eradication  Commission,  Atlantic  City,  N.  J., 

January  31,  191S,  materially 

revised,  enlarged  and  brought  down  to  date 


TO 
MAJOR-GENERAL  W.  C.  GORGAS 

SURGEON-GENERAL,  U.  S.  A. 
Honorary  Chairman  National  Committee  on  Malaria 

In  grateful  appreciation  of  his  distinguished  services  to  the 

cause  of  malaria  eradication  in  Cuba 

and  the  Panama  Canal  Zone  and  the  prevention 

and  control  of 

malaria  throughout  the  World 


CONTENTS 
Part  I 

MODERN  ERADICATION  METHODS  AND  RESULTS 

Page 

Malaria  and  War .  .  . 7 

Essentials  of  Prophylaxis 8 

Decline  in  the  Malaria  Death  Rate 9 

Malaria  in  Southern  Cities 10 

Government  Morbidity  Statistics 11 

Malaria  in  Alabama  and  Louisiana 12 

Limitations  of  Morbidity  Returns 14 

Review  of  United  States  Malaria  Morbidity  Statistics 15 

Descriptive  Definition  of  Endemic  Areas 19 

Malaria  in  Mississippi 21 

Comparative  Frequency  of  Malaria  and  Typhoid 22 

Influence  of  Race 23 

Influence  of  Topography 23 

Distribution  in  Mississippi 26 

Malaria  in  the  Yazoo  Delta 27 

Eradication  Measures  in  Bolivar  County,  Miss 2&«» 

Quinine  Prophylaxis 29 

Malaria  Morbidity  of  Bolivar  County,  Miss 30 

Malaria  Morbidity  of  Washington  County,  Miss 30 

Eradication  Measures  in  Ashley  County,  Ark 31- 

Eradication  Measures  in  Chicot  County,  Ark 33- 

Entomological  Investigations  in  Louisiana 34 

Relation  to  Crop-Production 35 

Relation  of  Climate  to  Insect  Life 36 

Land  Reclamation  and  Drainage ■  37 

Mosquito  Extermination  in  New  Jersey 39 

Mosquito  Extermination  in  Essex  County 40 

Work  of  Mosquito  Extermination  Commissions 41 

Malaria  Eradication  in  New  York  City 43 

Problems  of  Clinical  Diagnosis 46 

Malaria  Eradication  in  California 48 

Economic  Aspects  of  Extermination  Measures 52 

Malaria  Control  Work  in  India 53 

Malaria  Control  Work  in  Burma 55 

Malaria  Survey  of  Central  Provinces 56 

Rice  Cultivation  and  Malaria: 58 

Advisory  Board  of  the  Straits  Settlements 60 


CONTENTS,  Continued 

Page 

New  Methods  of  Educational  Propaganda 62 

.^Eradication  Measures  in  Argentina 65 

Argentina  Malaria  Morbidity  Statistics 66 

Malaria  in  Peru  and  Ecuador ' 69 

Malaria  in  Swaziland  and  Cyprus 70 

Comparative  Pan-American  Malaria  Statistics 71 

Workmen's  Compensation  for  Malarial  Diseases 73 

Recent  Municipal  Ordinances  on  Legal  Requirements  for  Reporting 

of  Malarial  Diseases 75 

Part  II 
MALARIA  IN  RELATION  TO  WAR 

Malaria  in  the  Civil  War 79 

Malaria  in  Prison  Camps 80 

Methods  of  Quinine  Prophylaxis 80 

Malaria  in  the  European  War  Area 81 

Malaria  and  "Trench  Fevers" 82 

Malaria  in  the  Western  War  Area 84 

Malaria  in  the  Eastern  War  Area ' 84 

Recurrence  in  Belgium  and  Northern  France 86 

Clinical  Aspects  of  Malaria  Control 86 

Urgency  of  Drastic  Preventive  Measures 87 

Practical  Military  Aspects  of  Malaria  Control 88 

Report  of  French  Malaria  Commission 92 

French  Methods  of  Prophylaxis 92 

Modern  Conclusions  Based  on  War  Experience 95 

Malaria  Prevalence  in  Army  Cantonments 97 

Malaria  in  the  United  States  Army  Medical  Experience. 99 


THE 

MALARIA  PROBLEM  IN 

PEACE  AND  WAR 


PARTI 

MODERN  MALARIA  ERADICATION 
METHODS  AND  RESULTS 

PART  II 
MALARIA  IN  RELATION  TO  WAR 


1918 

PRUDENTIAL  PRESS 

NEWARK.  N.  J. 

U.  S.  A. 


PART  I 

MODERN  MALARIA  ERADICATION 
METHODS  AND  RESULTS 

The  immensity  of  the  problem  of  malaria  eradication  would  be 
absolutely  appalling,  were  it  not  for  the  encouraging  and  increasing 
evidence  of  a  material  reduction  in  the  rate  of  malaria  frequency  in  prac- 
tically every  locality  or  section  where  modem  methods  of  disease  pre- 
vention and  control  have  been  vigorously  and  continuously  carried  into 
effect,  although  naturally  with  a  widely  varying  degree  of  success  in  the 
results  achieved.  The  possibilities  of  more  or  less  complete  malaria 
eradication  in  restricted  areas  are,  therefore,  no  longer  questioned  by  any 
one  familiar  with  the  recorded  facts  of  a  public-health  problem  of  the 
utmost  practical  importance  to  large  numbers  of  our  own  population 
and  the  peoples  of  other  and  still  more  afflicted  countries. 

MALARIA  AND  WAR 

Malaria,  while  primarily  a  health  and  engineering  problem  of  the 
semitropics  and  the  tropics,  is  nevertheless  a  disease  of  world-wide 
distribution,  and  the  menace  of  its  occurrence  and  reintroduction  into 
regions  relatively  or  entirely  free  therefrom  is  best  illustrated  by  its 
lamentable  recurrence  among  the  Allied  armies  in  Flanders  and  northern 
France.  Unhappily,  the  impressive  lessons  of  past  military  experience 
have  apparently  been  ignored,  and  "large  numbers  of  troops  are  rendered 
inefficient  for  considerable  periods  by  autumnal  fever,  as  it  is  called, 
and  this  to  an  extent  which  seriously  handicaps  the  military  position."* 
As  pointed  out  by  Surgeon-Major  E.  Rist,  of  the  French  Scientific 
Mission,  in  an  address  before  the  American  Public  Health  Association 
(October  19,  1917),  there  have  occurred  "a  considerable  number  of 
cases  of  malaria  in  soldiers  returned  from  Saloniki,  Macedonia,  and  the 
Vardar- Valley,"  which  is  known  to  be  "one  of  the  most  malaria-infested 
places  in  the  world."  f     The  fever,  it  is  pointed  out,  is  "of  the  worst 

*A  fairly  extended  descriptive  account  of  acute  contagious  diseases  in  the  French  army  by  Surgeon-Major 
E.  Rist,  of  the  French  Scientific  Commission,  was  read  before  the  general  session  of  the  American  Public  Health 
Association,  October  19,  1917,  at  Washington,  D.  C, reprinted  in  the  Decemberissue  of  The  American  Journal 
of  Public  Health. 

t"Salonika,  however,  not  only  suffers  from  bad  government,  but  also  from  the  marshes  which  surround  it, 
and  in  summer  many  of  its  inhabitants  flock  to  the  healthier  town  of  Kalameria,  to  the  west.  Miasmatic 
swamps  unfortunately  occupy  a  large  portion  of  the  northern  coast  of  the  Aegean,  and  they  separate  the  interior 
of  Macedonia  more  effectively  from  the  coast  than  do  its  mountains." — Elisee  Reclus,  "The  Earth  and  Its  In- 
habitants," Europe,  Vol.  I,  p.  110. 


tropical  kind."  The  cases  are  treated  in  special  hospitals,  "located  in 
such  regions  where,  after  a  careful  entomological  survey,  it  has  been 
proved  that  there  are  no  anopheline  mosquitoes.  No  malarial  hospital 
is  allowed  in  a  district  where  anophelines  are  present."  It  is  to  be 
hoped  that  these  and  other  precautions  will  be  adopted  in  the  final 
organization  of  the  Army  Medical  Service  in  connection  with  the  control 
of  the  disease  in  southern  cantonments  and  of  the  extra  cantonment  area 
under  the  supervision  of  the  United  States  Public  Health  Service.  For 
the  problem  is  a  much  more  serious  and  difficult  one  than  is  generally 
assumed  by  those  who  are  not  thoroughly  familiar  with  the  facts  of 
past  experience.  The  importance  and  the  duty  of  complete  protec- 
tion, therefore,  cannot  be  too  emphatically  insisted  upon.  The  Gov- 
ernment of  Australia,  with  commendable  foresight,  has  provided  for 
an  entomological  survey  of  the  areas  in  which  returning  soldiers  are  to 
be  provided  with  homesteads  and  in  which  the  prevalence  of  anopheline 
mosquitoes  would  constitute  a  permanent  menace  to  the  introduction  of 
the  disease  into  sections  of  Australia  now  relatively  or  entirely  free 
therefrom.*  Similar  measures  should  be  applied  rigorously  to  every 
danger  area  in  the  South,  and  nothing  should  be  left  undone  to  especially 
safeguard  Northern  troops  against  the  risk  of  malaria  infection  by  any 
and  all  means  at  the  command  of  the  Army  Medical  Department  alld 
the  United  States  Public  Health  Service. 

ESSENTIALS  OF  PROPHYLAXIS 

In  the  words  of  Craig,  "The  subject  of  prophylaxis  in  the  malarial 
fevers  is  of  the  very  greatest  importance,  for  these  fevers  are  preventable, 
and  since  the  discovery  of  the  plasmodia  and  the  method  of  the  trans- 
mission of  these  parasites  by  the  mosquito,  we  are  in  a  position  to  control 
the  spread  of  fevers  of  malarial  origin."!  In  the  light  of  this  knowl- 
edge and  the  vast  amount  of  conclusive  experience  in  malaria  eradica- 
tion throughout  the  world,  the  spread  of  the  disease  among  large 
bodies  of  the  men  of  the  National  Army  would  not  only  be  a  military 
calamity  but  obvious  evidence  of  inefficiency  in  medical  and  sanitary 
administration. 

It  has  also  been  pointed  out  by  Craig  that  "The  success  of  malarial 
prophylaxis  is  very   largely  a  question  of  local   conditions   and  the 

•Service  Publication  No.  12,  Quarantine  Service,  Commonwealth  of  Australia,  Melbourne,  1917,  Report  on 
Malaria  Mosquito  Survey  of  Irrigation  Areas  in  the  Murray  River  District,  by  F.  H.  Taylor.  The  number  of 
deaths  from  malaria  in  the  Commonwealth  of  Australia  during  1916  was  only  50,  equivalent  to  1.0  per  100,000 
of  population. 

f'The  Malarial  Fevers,"  by  Charles  F.  Craig,  M.  D.,  New  York,  1909;  also  Bulletin  No.  6,  Office  of  the 
Surgeon-General,  Washington,  1914. 

8 


assistance  given  by  the  local  and  governmental  authorities."*  He 
emphasizes  four  different  methods  of  prophylaxis,  but  suggests  especial 
application  in  conformity  to  variations  in  local  conditions,  for  a  method 
most  useful  in  one  section  might  be  least  useful  in  another.  The  four 
methods,  not  necessarily  in  the  order  of  their  importance,  are 

1  The  prevention  of  the  development  of  the  Plasmodia  in  man  and  the  de- 
struction of  the  Plasmodia  in  infected  individuals.  Both  these  aims  are  accom- 
plished by  the  administration  of  quinine,  i.  e.,  quinine  prophylaxis. 

2  Destruction  of  the  mosquitoes  transmitting  malaria. 

3  Protection  of  man  from  the  bites  of  mosquitoes. 

4  Education  of  the  public  regarding  malarial  prophylaxis. 

DECLINE  IN  THE  MALARIA  DEATH  RATE 

The  available  knowledge  on  the  malaria  problem  is  fully  sufficient  for 
general  practical  purposes,  although  much  unquestionably  remains  to  be 
done  to  perfect  the  theory  of  adequate  prophylaxis  in  matters  of  detail,  f 
It  is  frequently  a  most  difficult  question  to  decide  whether  one  approved 
method  of  prevention  or  another  should  be  followed;  but  past  experience 
has  fully  demonstrated  the  far-reaching  possibilities  of  well-considered 
eradication  measures.  For  many  countries,  but  especially  for  the 
Southern  States  of  the  United  States,  the  available  statistical  evidence 
is  quite  convincing  that  the  mortality  from  malaria  during  recent  years 
has  been  decidedly  on  the  decline.  This  conclusion,  however,  applies 
more  generally  to  Southern  cities  than  to  the  rural  sections,  for  many  of 
which  no  trustworthy  information  can  be  secured  at  the  present  time. 
Combining  the  returns  for  seventeen  representative  Southern  urban 
communities,  with  an  aggregate  estimated  white  population  of  2,385,000 
in  1916,  it  appears  that  the  malaria  death  rate  decreased  during  the 
last  decade  from  8.2  per  100,000  in  1907  to  4.3  in  1916.  There  was, 
therefore,  an  actual  reduction  in  malaria  frequency  among  the  white 
population  of  3.9  per  100,000,  equivalent  to  47.6  per  cent.  The  decline, 
however,  was  neither  persistent  nor  uniform,  for  there  was  apparently 
an  increase  in  the  rate  between  1907  and  1909,  when  the  mortality 
reached  a  maximum  of  9.6.  Subsequently  thereto,  however,  the 
decrease  was  gradual  and  considerable,  to  the  minimum  rate  of  3.9 
previously  referred  to.  For  the  colored  population  of  the  seventeen 
Southern  cities,  with  an  aggregate  estimated  population  for  the  year  1916 
of  734,725,  the  malaria  death  rate  decreased  from  49.9  per  100,000  in 

♦Bulletin  No.  6,  Surgeon-General's  Office,  August,  1914,  Washington,  D.  C. 

tFor  some  exceptionally  interesting  recent  observations  on  New  Malaria  Problems  of  To-day,  see  an 
editorial  in  The  Lancet,  December  15,  1917,  p.  905. 


1907  to  15.9  in  1916.  There  was,  therefore,  an  actual  reduction  during 
the  decade  in  the  malaria  mortality  of  the  colored  of  34.0  per  100,000  of 
population,  equivalent  to  68.1  per  cent.  The  sanitary  progress  in  the 
seventeen  Southern  cities  considered  as  a  group  has  clearly  been  of 
decided  benefit  to  both  the  white  and  the  colored  population,  with  a 
consequential  material  saving  in  working-time,  medical  expense,  etc. 
The  death  rate,  of  course,  reflects  to  only  a  minor  degree  the  full  eco- 
nomic importance  of  malaria  as  a  sickness  problem.  The  details  of  the 
malaria  death  rate  of  Southern  cities  are  given  below : 

MORTALITY  FROM  MALARIA  IN  SEVENTEEN  SOUTHERN 

CITIES,  1907-1916 
(Rate  per  100,000  Population) 


WHITE 

Estimated 
Population 

1907 1,670,502 

1908 1,705,739 

1909 1,734,583 

1910 1,784,991 

1911 1,820,389 

1912 1,850,884 

1913 1,882,562 

1914 1,911,393 

1915 1,974,750 

1916 2,003,850 


COLORED 


No.  of 
Deaths 

137 

153 

166 

133 

119 

129 

98 

89 

103 

86 

1213 


Rate 

8.2 
9.0 
9.6 
7.5 
6.5 
7.0 
5.2 
4.7 
5.2 
4.3 

6.6 


Estimated 
Population 

618,688 
635,986 
647,994 
672,653 
689,941 
702,206 
715,178 
726,908 
722,244 
734,723 


No.  of 
Deaths 

309 
295 
250 
233 

285 
244 
223 
183 
188 
177 


Bate 

49.9 
46.4 
38.6 
34.9 
41.3 
34.7 
31.2 
25.2 
26.0 
15.9 

33.9 


1907-1916.18,339,643  1213         6.6         6,866,521         2,329 

(The  cities  included  in  this  investigation  are  Mobile,  Ala.,  Wash- 
ington, D.  C,  Jacksonville  and  Key  West,  Fla.,  Atlanta  and  Savannah, 
Ga.,  Louisville,  Ky.,  New  Orleans,  La.,  Raleigh,  N.  C,  Charleston, 
S.  C,  Memphis  and  Nashville,  Tenn.,  Galveston  and  San  Antonio, 
Texas,  Richmond  and  Norfolk,  Va.,  and  Baltimore,  Md.) 

MALARIA  IN  SOUTHERN  CITIES 
It  would  unduly  enlarge  the  present  discussion  to  consider  at  length 
the  reductions  achieved  in  each  and  every  one  of  the  seventeen  cities, 
which  naturally  vary  widely,  in  consequence  of  essential  differences  in 
local  methods  of  eradication  and  local  conditions  responsible  for  malaria 
prevalence.     Especially  significant,  however,  is  the  decrease  in  the 


10 


malaria  mortality  of  the  city  of  Memphis,  where  the  local  problem  is 
one  of  exceptional  complexity,  on  account  of  the  proximity  of  a  vast 
extent  of  infected  territory,*  which  unquestionably  accounts  for  a  con- 
siderable proportion,  if  not  the  major  proportion,  of  the  malaria  mor- 
tality of  residents  and  non-residents  combined.  Between  1906  and  1916 
the  mortality  from  malaria  of  the  white  population  of  Memphis  decreased 
from  65.4  per  100,000  to  24.4,  or  actually  41.0  per  100,000,  equivalent  to  a 
reduction  of  62.7  per  cent.  The  corresponding  decrease  in  the  malaria 
mortality  of  the  colored  population  has  been  from  232.6  at  the  beginning  of 
the  period  to  63.7  at  the  end !  The  actual  decrease  in  the  mortality  of  the 
colored  population  was  therefore  168.9  per  100,000,  equivalent  to  72.6 
per  cent.  This  extraordinary  and  gratifying  reduction  unquestionably 
reflects  local  sanitary  progress  of  a  high  order  and  the  efficacy  of  local 
antimalarial  measures,  which,  it  may  be  suggested,  should  be  made  the 
subject  of  an  extended  official  report;  for  whatever  specific  method  or 
means  may  have  been  adopted  and  carried  into  effect  to  bring  about 
this  remarkable  change  in  health  conditions  is  not  merely  a  matter  of 
serious  concern  to  the  city  of  Memphis,  but  to  many  other  localities 
where  local  conditions  may  be  more  or  less  similar  and  where  the  attained 
reduction  in  the  malaria  death  rate  has  been  at  a  lesser  rate.  Equally 
encouraging,  however,  has  been  the  reduction  in  the  malaria  death  rate 
of  the  city  of  Nashville.  During  1906  the  malaria  death  rate  of  the 
white  population  was  22.3  per  100,000  of  population,  against  a  rate  of 
only  1.2  in  1916;  in  other  words,  malaria  in  Nashville  has  practically 
been  eradicated.  For  the  colored  population  the  corresponding  reduc- 
tion was  from  45.2  per  100,000  at  the  beginning  of  the  period  to  only 
5.5  at  the  end!  As  a  matter  of  fact,  there  was  only  one  death  from  malaria 
among  the  white  population  of  Nashville  during  1916,  estimated  at 
80,600,  and  only  two  deaths  from  this  disease  among  the  colored  popu- 
lation, estimated  at  36,500! 

GOVERNMENT  MORBIDITY  STATISTICS 

The  foregoing  observations  have  reference  exclusively  to  the  mortality 
from  malaria  in  selected  but  representative  urban  centers  of  the  Southern 
States.  Through  the  United  States  Public  Health  Service,  under  the 
direction  of  Dr.  H.  R.  Carter,  efforts  are  being  made  to  secure  malaria 
morbidity  statistics  through  the  active  cooperation  of  practising  physi- 
cians of  the  South.  The  results  have  been  sufficiently  encouraging  to 
warrant  the  continuation  of  this  plan,  though  perhaps  in  a  somewhat 

*The  river  bottom-lands  of  eastern  Arkansas. 

11 


modified  form.  If  complete  cooperation  could  be  secured,  the  results 
would  unquestionably  be  of  the  first  importai^e.  That  the  complete 
reporting  of  all  cases  of  malaria  and  other  fevers  is  not  really  a  serious 
practical  difficulty  has  been  completely  demonstrated  in  the  State  of 
Mississippi,  where  under  the  direction  of  Dr.  W.  S.  Leathers,  the 
State  Health  Officer,  returns  are  now  being  made  by  nearly  all  the 
physicians  of  the  State. 

The  procedure  of  the  United  States  Public  Health  Service  is  to  send 
out  return-reply  postcards  to  physicians  in  actual  practice  and  to 
require  a  monthly  staltement  of  the  number  of  cases  of  malarial  fever 
treated  during  the  period,  according  to  race,  type  of  disease  and 
whether  confirmed  microscopically  or  not.  This  plan  was  initiated 
by  the  late  Dr.  R.  H.  von  Ezdorf,  who  in  1915  presented  the  results  of  a 
first  survey  of  malaria  in  the  United  States  with  reference  to  its  prev- 
alence and  geographic  distribution,  based  on  181,590  cards  mailed  to 
physicians  and  24,072  replies  received  in  return.  It  is  therefore  shown 
that  13.25  per  cent,  of  the  physicians  made  replies,  the  range  being 
from  a  minimum  of  8.02  per  cent.,  for  Louisiana,  to  a  maximum  of  16.54 
per  cent.,  for  Arkansas.  The  number  of  cases  of  malaria  reported  was 
81,085.  The  population  considered  was  15,112,000,  equivalent  to  a 
morbidity  rate  of  5.36  per  1,000.  According  to  Dr.  von  Ezdorf,  "If 
the  same  ratio  is  carried  out  on  the  basis  of  complete  returns,  then  the 
morbidity  rate  would  be  40.4  per  1,000;  that  is,  4  per  cent,  of  the 
population,  or  over  600,000  people,  in  the  eight  States  suffered  an  attack 
of  malaria."  The  States  in  question  were  Alabama,  Arkansas,  Florida, 
Kentucky,  Louisiana,  North  Carolina,  South  Carolina  and  Tennessee.* 

MALARIA  IN  ALABAMA  AND  LOUISIANA 

In  1916  Dr.  von  Ezdorf  made  a  supplementary  report  on  "The 
Endemic  Index  of  Malaria  in  the  United  States,"!  including  an  estimate 
for  twelve  Southern  States  with  a  population  of  25,000,000,  a 
morbidity  rate  of  four  per  cent.,  and  an  estimated  mortality  of  one 
death  from  malaria  out  of  every  fifty  to  three  hundred  cases  of  the 
disease.  In  continuance  of  the  work  inaugurated  by  Dr.  von  Ezdorf, 
special  reports  have  been  made,  among  others,  on  malaria  in  Ten- 
nessee, Louisiana,  Kentucky,  eastern  Texas,  North  Carolina,  Alabama, 
etc.     All  of  these  reports  indicate  a  maximum  frequency  of  malaria 

•For  the  State  of  Mississippi  for  the  two  years  1915  and  1916,  the  malaria  morbidity  rate  as  ascertained  by 
trustworthy  methods  not  at  present  followed  by  any  other  Southern  State  was  80.9  per  1,000,  or  8.1  per  cent. 

f'Malarial  Index  Work,"  by  R.  H.  von  Ezdorf,  Reprint  No.  159,  U.  S.  Public  Health  Reports,  Decem- 
ber 26,  1913,  Washington,  1914.     See,  also,  his  "Anopheline  Surveys,"  Reprint  No.  272,  April  30,  1915. 

12 


morbidity  during  the  month  of  September.  In  Alabama  for  the  year 
1916  only  twelve  per  cent,  of  the  physicians  circularized  returned  the 
schedules.  It  is  therefore  pointed  out  in  the  report  that  "While  there 
must  have  been  many  more  cases  of  malaria  in  the  State,  the  reports  of 
the  physicians  on  which  this  study  is  based  are  sufficient  to  show  whether 
malaria  was  present  or  absent  in  the  several  counties,  and  reasonably 
accurately  the  relative  intensity  of  the  infection  in  the  counties."  As 
an  illustration  of  the  results  of  this  method  of  securing  malaria  mor- 
bidity returns  by  circularizing  practising  physicians,  the  following  table 
is  included  for  the  State  of  Alabama.  It  may  be  said  in  this  connection 
that  there  were  three  cases  of  hemoglobinuric  fever*  reported  from 
Marengo  County  during  the  fourth  quarter  of  1916. 

MALARIA  MORBIDITY  IN  ALABAMA 

1915-1916 
(U.  S.  Public  Health  Service) 

1915 

Inquiry  Cards       n-„i;„<,  p„,„<.„f„„^     Counties       Counties      Cases  of 

Period  Sent  to  ReSd         of  ReDliM  K^P'^«°te<^  Not  Heard    Malaria 

Physicians         "eceived         ot  KepUes     inRepUgg         j-^o^,        Reported 

January  to  March 7,050  926  13.13  67  ..  1,170 

April  to  June 2,350  307  13.06  65  2  1,810 

July  to  September....  2,350  257  10.94  63  4  4,535 

October  to  December.  2,350  294  12.51  62  5  1,929 

1916 

January  to  March 2,350          254  10.81  62  5  659 

April  to  June 2,350          279  11.87  64  3  2,393 

July  to  September. ...  2,350          261  11.11  64  3  6,261 

October  to  December.  2,350          256  10.89  63  4  1,695 

To  facilitate  a  comparison  with  the  returns  for  another  typical 
Southern  State  in  which  malaria  is  relatively  common,  or  at  least  in 
certain  sections  thereof,  the  following  table  for  the  State  of  Louisiana 
is  included.  There  were  ten  cases  of  hemoglobinuric  fever  reported 
from  five  different  parishes  of  Louisiana  during  the  third  and  fourth 
quarters  of  1916. 

♦For  an  extended  discussion  on  hemoglobinuric  fever,  see  "The  Malarial  Fevers,  Haemoglobinuric  Fevers," 
etc.,  by  Chas.  F.  Craig,  New  York,  1909,  part  vi,  p.  391,  et  seq.;  "The  Endemic  Diseases  of  the  Southern  States," 
by  Deaderick  and  Thompson,  chapter  on  Blackwater  Fever,  p.  219,  el  seq.;  "Blackwater  Fever,"  by  A.  G. 
Newell,  London,  1909;  Report  on  Blackwater  Fever,  by  Captain  S.  R.  Christophers  and  Dr.  C.  A.  Bentley, 
Calcutta,  1909;  also  a  Report  on  Hemoglobinuric  Fever  in  the  Canal  Zone,  by  W.  E.  Decks,  M.  D.,  and  W.  M. 
James,  M.  D.,  Mount  Hope,  Canal  Zone,  1911. 

13 


MALARIA  MORBIDITY  IN  LOUISIANA 

1915-1916 
(U.  S.  Public  Health  Service) 

1915 

Inquiry  Cards       Bpnijpe         Pprrpntajrp     Parishes        Parishes       Cases  o( 

Period  Sent  to  tJ:!^!'?^        ^ifD^i^ff  Represented  Not  Heard    Malaria 

Physicians         Received         of  Rephes     ^^^^^^^^         p.„^        Reported 

January  to  March 7,500  692  9.23  63  2  1,456 

April  to  June 2,070  320  15.46  60  5  2,754 

July  to  September. .. .   2,070  191  9.23  49  16  5,133 

October  to  December.   2,070  191  9.23  49  15  3,249 

1916 

January  to  March 2,070          142  6.86  55  9  2,239 

April  to  June 2,070          128  6.18  48  16  3,178 

July  to  September....   2,070          188  9.08  47  17  7,040 

October  to  December.   2,070          136  6.57  44  20  2,450 

Granting  the  decided  limitations  to  investigations,  the  data  are 
nevertheless  of  some  practical  value.  They  certainly  emphasize  the 
excessive  prevalence  of  malaria  in  the  months  of  July-September  and 
a  minimum  occurrence  of  the  disease  during  January-March.  They 
require  to  be  amplified  considerably  in  matters  of  detail,  and  un- 
questionably much  could  be  done  to  improve  the  tabular  presentation 
of  the  results.  The  type  of  infection  should  be  determined  with  greater 
accuracy,  but  at  the  outset  it  would  not  seem  wise  to  overemphasize 
the  method  of  diagnosis,  whether  clinical  or  microscopical.  The 
accuracy  and  completeness  of  the  method  depend,  of  course,  upon 
the  active  and  intelligent  cooperation  of  every  physician  practising  in 
the  areas  reported  upon.  There  are,  unfortunately,  convincing  reasons 
for  believing  that  many  physicians  fail  in  clearly  realizing  their  pro- 
fessional duty  to  cooperate  to  the  fullest  extent  required  with  the  United 
States  Public  Health  Service  or  the  State  health  authorities. 

LIMITATIONS  OF  MORBIDITY  RETURNS 

Uniformity  in  procedure  in  such  an  investigation  is  most  essential,  if 
the  data  are  to  be  of  value  for  comparative  purposes.  Where  the  State 
health  administration  is  thoroughly  eflScient,  as,  for  illustration,  in  the 
state  of  Mississippi,  excellent  results  can  be  secured,  and  possibly  even 
better  results  than  through  the  United  States  Public  Health  Service, 
Adequate  provision,  however,  requires  to  be  made  for  promptness  and 

14 


completeness  in  the  tabulation  and  analysis  of  the  returns.  In  this 
respect  the  method  followed  by  the  State  of  Mississippi  is  more  satis- 
factory, for  the  information  is  made  available  within  less  than  thirty 
days  after  the  reports  are  received.  Under  our  form  of  State  health 
administration  the  United  States  Public  Health  Service  is  without 
power  of  legal  compulsion  in  the  making  of  the  returns  required.  It 
has  no  jurisdiction  over  local  health  officers  and  practising  physicians, 
so  that  efforts  for  an  improvement  in  the  accuracy  of  the  Federal 
returns  depend  primarily  upon  a  higher  sense  of  realized  duty  on  the 
part  of  the  medical  profession.  Where  such  cooperation  cannot  be 
secured  it  would  therefore  seem  best  that  the  matter  should  be  one  of 
State  administration^  but  as  far  as  practicable  the  methods  of  pro- 
cedure, the  forms  and  blanks  and  the  tabulation  and  analysis  should  be 
in  conformity  to  those  followed  by  the  United  States  Public  Health 
Service  materially  improved,  of  course,  as  experience  would  suggest. 

REVIEW  OF  UNITED  STATES  MALARIA  MORBIDITY 
STATISTICS 

The  serious  limitations  of  the  malaria  morbidity  statistics  of  the 
United  States  Public  Health  Service  are  best  illustrated  by  a  retro- 
spective review  of  the  data  for  selected  Southern  States  for  each  of  the 
last  five  years,  showing,  respectively,  the  number  of  cards  sent  out,  the 
number  of  replies  received  from  practising  physicians  and  the  percentage 
of  such  replies  to  the  total.*  The  table  following  presents  the  data  for 
the  State  of  Alabama. 

UNITED  STATES  PUBLIC  HEALTH  SERVICE  MALARIA 

STATISTICS  FOR  THE  STATE  OF  ALABAMA 

1912-1916 

Y«r  Cards  Sent  EepUes  P«^|?^ 

1912 4,551  1,036  22.8 

1913 13,976  1,816  13.0 

1914 28,117  3,247  11.5 

1915 14,100  1,784  12.7 

1916 9,400  1,050  11.2 

Total 70,144  8,933  12.7 

•These  reports  are  published  annually  and  are  obtainable  free  of  charge  from  the  U.  S.  Public  Health 
Service,  Washington,  D.  C. 

15 


It  is  self-evident  that  the  effort  to  secure  malaria  morbidity  statistics 
for  the  State  of  Alabama  by  the  method  previously  described  in  sufficient 
detail  has  fallen  far  short  of  the  expected  results.  After  reaching  a 
maximum  of  28,117  cards  sent  out,  in  1914,  the  number  was  rapidly 
reduced  to  9,400,  in  the  year  1916.  The  reasons  for  this  reduction  are 
not  explained  in  the  official  reports  on  malaria  prevalence  by  States. 
The  percentage  of  replies  received  decreased  from  a  maximum  of  22.8, 
for  the  year  1912,  to  a  minimum  of  11.2,  for  the  year  1916.  For  practical 
purposes,  therefore,  the  effort  to  secure  malaria  morbidity  statistics  for 
the  State  of  Alabama  through  the  efforts  of  the  United  States  Public 
Health  Service  must  be  considered  a  failure.  The  average  proportion  of 
replies  received  for  the  five-year  period  for  the  State  of  Alabama  was  only 
12.7  per  cent. 

For  the  State  of  Arkansas  the  returns  have  only  been  published  for 
1913  and  1914,  with  a  resulting  average  percentage  of  replies  of  17.4. 
The  percentage  of  replies  received  decreased  from  20.8  in  1913  to  16.5 
in  1914.  No  information  has  been  made  public  as  to  why  the  collection 
of  data  for  the  State  of  Arkansas  was  discontinued.  For  the  State  of 
Florida  the  returns  are  available  for  four  years.  The  details  of  the  in- 
vestigation are  presented  in  the  table  following: 

UNITED    STATES  PUBLIC  HEALTH  SERVICE  MALARIA 
STATISTICS  FOR  THE  STATE  OF  FLORIDA,  1913-1916 

Year  Cards  Sent  Replies  oflljnes 

1913 3,842  776  20.2 

1914 11,603  1,273  11.0 

1915 2,928  431  14.7 

1916 3,928  498  12.7 

Total 22,301  2,978  13.4 

The  number  of  cards  sent  out  varied  widely  during  the  four  years, 
but  during  1916  about  the  same  number  was  sent  out  as  during  the 
year  1913.  The  percentage  of  replies  received,  however,  decreased  from 
20.2  in  1913  to  12.7  in  1916.  The  wide  variation  between  the  number  of 
cards  sent  out  and  the  number  of  replies  received  indicates  that  the  results 
of  the  investigation  are  probably  of  very  limited  value.  The  average 
proportion  of  replies  received  for  the  State  of  Florida  for  the  four-year 
period  was  13.4  per  cent. 

For  the  State  of  Georgia  it  would  appear  that  only  one  effort  was  made, 
during  the  year  1913,  when  9,000  cards  were  sent  out  and  1,084  replies 

16 


were  received,  or  12.0  per  cent.  There  is  nothing  to  indicate  in  the 
reports  for  subsequent  years  why  the  effort  to  secure  malaria  mor- 
bidity statistics  for  the  State  of  Georgia  was  discontinued.  For  the 
State  of  Kentucky  the  returns  have  been  made  public  for  the  three 
years  1914-1916.  The  details  of  the  investigation  are  presented  in  the 
next  table : 

UNITED   STATES  PUBLIC  HEALTH   SERVICE   MALARIA 
STATISTICS  FOR  THE  STATE  OF  KENTUCKY,  1914-1916 

Year  Cards  Sent  Replies  JfRi^uii 

1914 20,990  3,334  15.9 

1915 21,000  3,432  16.3 

1916 14,000  1,519  10.9 

Total 55,990  8,285  14.8 

The  number  of  cards  sent  out  increased  slightly  from  1914  to  1915, 
but  was  reduced  by  about  one-third  during  1916.  For  the  three-year 
period  the  average  number  of  replies  received  for  the  State  of  Kentucky 
was  14.8  per  cent.  Equally  unsatisfactory  have  been  the  results  for  the 
State  of  Louisiana,  as  shown  by  the  table  below: 

UNITED   STATES   PUBLIC  HEALTH  SERVICE  MALARIA 
STATISTICS  FOR  THE  STATE  OF  LOUISIANA,  1914-1916 

Year  Cards  Sent  Replies  ^{  Replies 

1914 19,981  1,603  8.0 

1915 13,710  1,394  10.2 

1916 8,280  594  7.2 

Total 41,971  3,591  8.6 

From  a  maximum  of  nearly  20,000  cards  sent  out  in  1914,  the  number 
was  reduced  to  less  than  one-half  in  1916.  The  proportion  of  replies 
received  changed  from  8.0  per  cent,  in  1914  to  10.2  per  cent,  in  1915, 
reaching  a  minimum  of  7.2  per  cent,  in  1916.  The  average  for  the 
State  of  Louisiana  for  the  three-year  period  was  only  8,6  per  cent. 

For  North  and  South  Carolina  the  returns  are  equally  unsatisfactory. 
For  both  States  the  number  of  cards  sent  out  during  1916  was  very 
much  below  the  number  sent  out  during  the  previous  two  years.  The 
proportion  of  replies  received  was  lowest  during  1916.     The  average 

17 


number  of  replies  for  the  four-year  period  was  practically  the  same  for 
the  two  states,  or  15.9  per  cent,  for  North  Carolina  and  15.2  per  cent, 
for  South  Carolina.  The  details  of  the  analysis  are  presented  in  the 
table  following: 

UNITED  STATES  PUBLIC   HEALTH   SERVICE  MALARIA 

STATISTICS  FOR  NORTH  AND  SOUTH 

CAROLINA,  1913-1916 

NORTH  CAROLINA 

Year  Cards  Sent  Replies  o^Re^plfes 

1913.. 1,849  408  22.1 

1914 21,126  3,320  15.7 

1915 11,094  1,759  15.9 

1916 7,396  1,090  14.7 

Total 41,465  6,577  15.9 

SOUTH  CAROLINA 

1913 5,100  950  18.6 

1914 15,246  2,445  16.0 

1915 7,650  1,045  13.7 

1916 3,825  399  10.4 

Total 31,821  4,839  15.2 

In  addition  to  the  foregoing  Southern  States,  the  information  is  avail- 
able for  Tennessee  and  East  Texas.  The  details  of  the  investigation  for 
Tennessee  are  presented  in  the  next  table: 

UNITED  STATES  PUBLIC   HEALTH  SERVICE  MALARIA 
STATISTICS  FOR  THE  STATE  OF 
TENNESSEE,  1913-1916 

Ye«  Cards  Sent  Replies  liiSX' 

1913 3,338  609  18.2 

1914 39,594  4,724  11.9 

1915 20,028  1,792  8.9 

1916 13,352  963  7.2 

Total 76,312  8,088  10.6 

The  table  proves  conclusively  the  limitations  of  the  method  at  present 
made  use  of  by  the  United  States  Public  Health  Service  to  secure 

18 


malaria  morbidity  statistics  of  intrinsic  value  for  the  several  Southern 
States  and  the  separate  counties  thereof.  No  reasons  are  advanced 
why  the  proportion  of  replies  should  have  continuously  diminished 
from  18.2  per  cent,  in  1913  to  7.2  per  cent,  in  1916.  For  the  State  of 
Tennessee  during  the  four-year  period  the  average  proportion  of  replies 
received  was  10.6  per  cent.  For  East  Texas  the  proportion  of  replies 
in  1915  was  16.0  per  cent.,  but  for  1916  only  11.7  per  cent.,  or  for  the  two 
years  combined,  13.8  per  cent. 

DESCRIPTIVE  DEFINITION  OF  ENDEMIC  AREAS 
It  has  seemed  advisable  to  present  these  data  in  some  detail,  on  account 
of  the  possibility  that  the  Government  statistics  may  be  utilized  for  prac- 
tical purposes,  but  in  a  very  misleading  manner.  If  the  intrinsic  value  of 
these  returns  cannot  be  improved,  and  if,  as  a  matter  of  fact,  the  tendency 
is  strongly  in  the  direction  of  a  diminished  trustworthiness,  it  would 
seem  best  to  discontinue  the  collection  and  publication  of  such  data 
altogether.  It  is  suggestive  in  this  connection  that,  although  malaria  is 
referred  to  at  considerable  length  with  regard  to  its  scientific  and  other 
aspects  in  the  last  annual  report  of  the  Surgeon-General  of  the  United 
States  Public  Health  Service,  there  is  no  mention  of  the  statistical 
returns  obtained  by  means  of  circularizing  the  physicians  of  most 
of  the  Southern  States,  further  than  that  the  method  itself  is  referred  to 
as  being  employed  "to  ascertain  as  definitely  as  this  means  would  allow 
the  prevalence  of  malaria."  In  a  general  way,  no  doubt,  the  data  were 
utilized  by  the  Public  Health  Service  for  the  ascertainment  of  the 
geographical  distribution  of  malaria,  it  being  said  in  the  report  that 

There  are  three  principal  well-recognized  endemic  areas, — one  large  area  and 
two  smaller  ones.  The  large  endemic  area  covers  the  whole  southeastern  por- 
tion of  the  United  States,  having  for  its  southern  boundary  the  Gulf  of  Mexico; 
for  its  western  boundary,  a  line  drawn  from  Eagle  Pass,  on  the  Rio  Grande,  to 
Leavenworth,  Kans. ;  for  its  eastern  boundary,  the  Atlantic  seaboard;  its 
northern  boundary  a  line  drawn  from  Leavenworth,  Kans.,  eastward  some 
distance  north  of  the  Ohio  river  and  extending  to  the  Atlantic  on  a  line  with  the 
northern  boundary  of  Maryland.  Of  the  two  smaller  endemic  areas,  one  in- 
cludes a  section  of  the  northern  part  of  New  Jersey,  southeastern  New  York, 
Connecticut,  Rhode  Island,  and  part  of  the  State  of  Massachusetts.  The 
third  recognized  endemic  area  is  in  CaUfomia,  and  includes  the  Sacramento 
and  San  Joaquin  VaUeys,  which  occupy  a  large  portion  of  the  central  part  of 
the  State.  It  is  probable  that  the  New  England  endemic  area  actually  extends 
southward  to  the  large  southern  area  of  which  it  is  really  a  part. 

Since  these  observations  are  not  sustained  by  definite  statistical  data 
such  as  might  be  forthcoming  if  the  eflFort  to  circularize  practising 

19 


physicians  throughout  at  least  the  more  or  less  endemic  areas  could  be 
made  more  successful,  these  conclusions,  of  course,  cannot  be  accepted  as 
final.  Granting  that  mortality  data  are  less  conclusive  than  accurate 
morbidity  data  when  properly  collected  and  otherwise  adequate  to  the 
purpose,  it  would  seem  best  for  the  time  being  to  make  more  extensive 
use  thereof  and  to  encourage  efforts  in  the  direction  of  improved  methods 
of  death  certification  and  the  tabulation  of  joint  causes,  so  as  to  meet  the 
practical  difiiculty  which  arises  out  of  a  practice,  more  or  less  justified,  of 
giving  the  preference  to  some  other  cause  of  death  than  malaria  where 
two  or  more  diseases  are  present  at  the  same  time.  It  is  properly  pointed 
\  out  in  this  connection  by  the  Surgeon-General  of  the  United  States 
•^Public  Health  Service  in  his  report  for  1917  that  out  of  13,000  cases  of 
malaria  in  the  United  States  Army  during  1904-1914  there  were  only  two 
deaths  directly  or  specifically  attributed  to  the  disease,  and  that  between 
1907  and  1914  there  were  7,000  cases  of  malaria  without  a  death.  In 
1914  the  highest  malaria  rate  at  any  Army  post  in  the  United  States  was 
73  per  1,000  mean  strength  at  Washington  Barracks  in  the  District  of 
Columbia.  The  second  highest  was  at  Fort  Myer,  Va.,  just  outside  of 
Washington,  and  the  third  highest  at  Fort  Leavenworth,  Kans.  The 
frequency  of  malaria  in  a  non-fatal  form  in  the  District  of  Columbia  is 
therefore  a  much  more  serious  medical  problem  than  is  generally  recog- 
nized by  both  the  medical  profession  and  the  public  at  large.* 

Aside  from  this  method  of  circularizing  physicians  in  actual  practice, 
the  United  States  Public  Health  Service  for  some  years  has  secured  re- 
turns of  the  notifiable  disease  in  large  and  small  cities,  f  The  inclusion 
of  malaria  has  been  most  fortunate,  and  in  time  a  consolidation  of  the 
report  should  prove  of  value.  As  pointed  out,  however,  with  reference 
to  the  returns  for  the  year  1916,  "some  of  the  cities  are  apparently  much 
more  successful  in  obtaining  reports  of  notifiable  disease  than  are 
others."  It  is  explained  therefore  that  "This  may  be  due  to  the  greater 
activity  of  their  health  department  or  to  a  greater  interest  in  the  public 
welfare  on  the  part  of  the  practising  physicians."  The  conclusion  is 
therefore  advanced  that  "The  completeness  of  the  notification  of  disease 
may  be  taken  as  a  fairly  dependable  index  of  the  efficiency  of  the  health 
department  and  of  the  sanitary  knowledge  and  training  of  its  personnel." 
Furthermore,  it  is  said  that  "To  so  great  an  extent  is  this  true  that  the 

•For  additional  observations  on  the  frequency  of  malaria  in  the  U.  S.  Army  before  the  present  war,  see  page 
79.  According  to  the  reports  of  the  Health  Officer  of  the  District  of  Columbia,  the  malaria  death  rate  of 
Washington,  D.  C,  during  the  two  years  1914  and  1915  was  only  0.8  for  the  white  and  1.5  per  100,000  for  the 
colored  population.     The  rate  decreased  from  7.4  per  100,000  during  1901-1905  to  0.8  during  1911-1915. 

tFop  a  further  discussion  of  malaria  notification,  see  p.  75,  et  seq. 

20 


small  number  of  cases  reported  in  some  cities  indicates  grossly  incom- 
plete reporting  of  cases  and  defective  health  administration,  and  not  an 
actual  freedom  from  disease."  What  is  true  of  notifiable  diseases  in 
general  is  particularly  true  of  malaria,  the  community  importance  of 
which  is,  unfortunately,  quite  often  disregarded,  by  both  the  author- 
ities and  the  physicians  in  general  practice.  The  latter,  however, 
are  often  much  more  to  blame  than  the  former.  Physicians  in- 
different to  statutory  requirements  intended  to  conserve  the  health 
and  the  welfare  of  the  community  are  not  likely  to  square  their  pro- 
fessional conduct  otherwise  with  the  highest  considerations  of  the  public 
good.  The  obligation  of  the  physician  to  report  each  and  every  case  of 
a  notifiable  disease  is  paramount  to  the  success  of  the  local  health 
administration,  and  those  derelict  in  this  respect  in  the  discharge  of  their 
public  duty  should  be  punished  according  to  law  and  to  the  fullest  extent. 
Conversely,  a  local  or  State  board  of  health  unwilling  to  enforce  statu- 
tory requirements  regarding  the  notification  of  infectious,  contagious  or 
otherwise  transmissible  diseases  fails  as  conspicuously  in  its  duty  of 
conserving  the  public  health,  and  the  incompetent  official  or  officials 
should  be  dealt  with  severely  according  to  their  deserts.  The  public 
health  is  no  longer  an  academic  problem,  but  a  matter  of  the  utmost 
practical  importance,  not  only  to  the  localities  directly  concerned,  but  to 
the  States  and  to  the  nation  of  which  they  are  a  part.* 

MALARIA  IN  MISSISSIPPI 

At  the  present  time  the  most  satisfactory  returns  regarding  malaria 
morbidity  are  those  of  the  State  of  Mississippi.  The  rules  and  regula- 
tions governing  morbidity  reports  are  concise,  but  sufficient  for  the  pur- 
pose. Section  I  reads  that  "It  shall  be  and  is  hereby  the  duty  of  county 
health  officers  to  secure  a  report  from  physicians  each  month  of  the 
diseases  named  in  Section  II  of  the  Rules  and  Regulations  of  the  State 
Board  of  Health  governing  the  morbidity  reports,  as  provided  in  Section 
2487  of  the  Mississippi  Code,  1906."  Among  the  diseases  included  are 
malaria  and  typhoid  fever.  Section  III  provides  that  "Each  and  every 
licensed  physician  practising  in  the  State  of  Mississippi  who  treats  or 
examines  any  person  suffering  from  or  afflicted  with,  or  suspected  to  be 

*The  inadequacy  of  the  notification  returns  is  most  regrettable.  The  data  as  published  by  the  Public 
Health  Service  in  their  present  form  cannot  be  utilized  to  much  practical  advantage.  The  responsibility  for 
their  inadequacy  rests,  of  course,  chiefly  with  the  local  health  departments.  In  no  direction,  perhaps,  could 
an  active  propaganda  on  the  part  of  the  National  Malaria  Committee  be  more  effective  than  in  a  direct  appeal 
to  the  citizenship  of  the  communities  concerned  for  the  more  complete  reporting  of  all  malaria  cases  on  the  part 
of  the  practising  physicians  and  an  insistent  demand  that  physicians  derelict  in  their  duty  to  report  such  cases 
be  dealt  with  according  to  law. 

21 


suffering  from  or  aflflicted  with  any  of  the  notifiable  diseases  named  in 
Section  II,  shall  on  the  first  day  of  the  month  following  report  the  num- 
ber of  each  disease  or  suspected  disease  to  the  County  Health  Officer  of 
the  County  in  which  the  patient  resides  or  is  temporarily  located.  Such 
reports  shall  show  the  number  of  cases  of  each  disease  by  color  or  race. 
When  the  physician  has  not  attended  any  cases  of  notifiable  disease 
during  the  month,  he  shall  report  such  fact  to  the  County  Health 
Officer."  In  practice  these  requirements  have  been  sufficient  for  the 
purpose.  Reports  are  received  promptly  from  practically  the  entire 
body  of  practising  physicians  in  the  State  of  Mississippi.  The  accuracy 
and  the  completeness  of  the  returns  are  a  most  commendable  and 
notable  achievement,  for  the  notifiable  diseases  include  also  puerperal 
septicemia  and  all  forms  of  tuberculosis  and  cancer.  The  returns 
constitute  the  first  reasonably  complete  morbidity  index  by  counties 
available  for  any  single  American  State  at  the  present  time.* 

COMPARATIVE  FREQUENCY  OF  MALARIA  AND  TYPHOID 

In  the  table  following,  the  returns  for  malaria  and  typhoid  fever  are 
summarized  for  the  two  years  1915-1916,  with  distinction  of  race. 

MORBIDITY  AND  MORTALITY  FROM  MALARIA  IN 
MISSISSIPPI,  1915-1916 
WHITE  COLORED 

Y»«,  ra<ieq  Rate  per  Dpatho    Rate  per  p  Rate  per  deaths  Rat«  P" 

lear  leases  lo.OOO  i^eatns       jo.OOO  ^^^^  10,000  ^eatns     jq.OOO 


1915 72,907  863.3    516   6.1 

1916 76,521  894.5    505   5.9 


80,800  746.6    976   9.0 
82,258  750.4    921   8.4 


MORBIDITY  AND  MORTALITY  FROM  TYPHOID  FEVER  IN 
MISSISSIPPI,  1915-1916 
WHITE  COLORED 

Year  Cases  Rate  per  Deaths      Rate  per         p  Rate  per        n-aths    Rate  per 

I  ear  ^.ases  lO.OOO  i^eains        lo.OOO  ^^ses  lO.OOO         Lieaia^      iqqqq 


1915 3,533       41.8         216       2.6 

1916 3,240      37.8         205       2.4 


2,629       24.3       404       3.7 
2,795       25.5       463       4.2 


The  interesting  fact  is  brought  out  by  this  comparison  that  both  the 
morbidity  and  the  mortality  rate  for  malaria  remained  practically  the 

*A  thoroughly  critical  and  practically  most  valuable  study  of  the  malaria  mortality  of  Baltimore,  by  Thayer 
and  Hewetson,  was  published  in  The  Johns  Hopkins  Hospital  Reports  of  1895,  including  a  study  of  some  fatal 
cases  of  malaria  by  Lewellys  F.  Barker;  see,  also,  in  this  connection  my  analysis  of  the  Statistical  Experience 
Data  of  the  Johns  Hopkins  Hospital,  Baltimore,  Md.,  1892-1911,  published  as  Monograph  No.  IV,  New 
Series,  Johns  Hopkins  Press,  Baltimore,  1913. 


same  for  the  two  races  during  the  two  years,  with  indications,  however, 
of  a  shght  decline  in  the  mortahty.  For  the  year  1916  the  malaria  mor- 
bidity rate  was  849.5  per  10,000  of  population  for  the  white  population, 
against  750.4  for  the  colored.  In  contrast,  however,  the  mortality  rate 
was  higher  for  the  negroes,  or,  respectively,  5.9  per  10,000  for  the  whites 
and  8.4  for  the  colored. 

There  was  a  slight  reduction  in  both  the  morbidity  and  the  mortality 
from  typhoid  fever  among  the  white  population,  and  a  slight  increase 
among  the  colored.  During  the  year  1916  the  typhoid  fever  morbidity 
was  37.8  per  10,000  for  the  whites,  against  25.5  for  the  colored;  in  con- 
trast, however,  the  typhoid  fever  rate  was  2.4  for  the  whites,  against  4.2 
for  the  colored.  For  both  malaria  and  typhoid  fever  the  death  rates 
for  the  colored  were  decidedly  in  excess  of  the  corresponding  rates  for 
the  whites,  although  the  relative  disease  incidence  was  less.  How  far 
the  latter  is  accounted  for  by  possible  inaccuracies  and  deficiencies  in  the 
reports  cannot  be  stated. 

INFLUENCE  OF  RACE 

It  is  of  interest  in  this  connection  to  emphasize  briefly  the  relative 
fatality  rates  for  the  two  diseases,  according  to  race.  Combining  the 
returns  for  the  two  years,  the  fatality  rate  for  malaria  was  0.7  per  cent, 
for  the  whites,  against  1.2  for  the  colored.  The  corresponding  rates  for 
typhoid  fever  were  6.2  for  the  whites  and  16.0  for  the  colored.  These 
results  are  in  conformity  to  other  investigations,  including  the  thor- 
oughly trustworthy  experience  data  of  the  Johns  Hopkins  Hospital.* 
With  rare  exceptions  the  fatality  rate  is  higher  for  the  negro  in  all  the 
infectious  diseases,  including  malaria,  f 

INFLUENCE  OF  TOPOGRAPHY 

A  discussion  of  the  geographical  distribution  of  malaria  throughout 
Mississippi,  with  a  due  regard  to  geographic  and  topographic  subdivi- 
sions of  the  State,  would  make  a  most  interesting  contribution  to 
the  subject,  f  Naturally,  of  special  importance  is  the  well-known 
excessive  prevalence  of  the  disease  in  the  twelve  so-called  "Delta"  coun- 
ties.     Physiographically  Mississippi  is  divisible  into  nine  regions,  which 

*The  Statistical  Experience  Data  of  the  Johns  Hopkins  Hospital,  Baltimore,  Md.,  1892-1911,  Monograph 
No.  IV,  New  Series,  The  Johns  Hopkins  Hospital  Reports,  Baltimore,  1913. 

fit  should  have  been  stated  that  the  estimated  white  population  of  Mississippi  is  approximately  850,000  and 
the  colored  population  about  1,096,000. 

IMississippi  State  Geological  Survey,  E.  N.  Lowe,  Director,  Bulletin  No.  12,  "Mississippi,  Its  Geology, 
Geography,  Soil  and  Mineral  Resources,"  1915,  Jackson,  Miss. 

23 


conform  quite  closely  to  the  geologic  structure  of  the  State.  For  the 
present  purpose,  however,  it  has  been  necessary  to  limit  the  geographical 
correlation  of  malaria  to  five  broadly  defined  topographical  regions, 
which  in  general  descriptive  terms  are  as  follows: 

Section  I. — Delta  Counties  (twelve),  containing  an  approximate  area 
of  7,712  square  miles  and  a  population  of  368,463  for  the  census  year  1910. 
This  region,  which  is  also  known  as  the  Yazoo  Delta,  according  to  the 
report  of  the  Mississippi  State  Geological  Survey,  "embraces  all  that 
great  flood  plain  deposit  of  the  Mississippi  River  and  its  tributaries 
lying  on  the  east  side  of  the  great  river  between  Memphis  and  Vicks- 
burg.  It  is  a  low-lying  featureless  expanse,  sloping  gently  southward. 
Its  altitude  at  the  Tennessee  line  is  200  feet  and  at  Vicksburg  100. 
The  whole  region  was  originally  heavily  timbered.  Large  forests  still 
remain,  but,  on  account  of  the  valuable  hardwood,  are  being  rapidly 
cut  over  and  the  lands  prepared  for  cultivation.  While  the  average 
relief  of  this  region  is  but  slight,  the  higher  lands  lie  adjacent  to  the 
streams,  the  interstream  areas  being  low  and  more  or  less  swampy. 
The  soils  are  all  alluvial  and  among  the  most  fertile  on  earth.  Until  the 
completion  of  the  levee,  the  annual  overflows  of  the  Mississippi  retarded 
very  much  the  development  of  the  Delta.  Since  then  development  has 
been  rapid,  and  with  the  completion  of  the  drainage  schemes*  now  being 
pushed  in  most  parts  of  this  region,  two-thirds  of  the  lands  now  unused 
will  be  reclaimed."! 

Section  II. — Southern  River  Counties  (five),  containing  an  approximate 
area  of  2,661  square  miles  and  a  total  population  of  116,452  for  the 
census  year  1910.  This  consists  in  part  of  a  wide  stream  margin  of 
rugged  precipitous  hills  known  as  the  Loess  or  Bluff  Hills,  through  which 
the  streams  have  cut  deep  narrow  gorges,  whose  sides  in  many  places 
stand  in  vertical  walls.  This  region  of  hills  varies  in  width  from  five  to 
fifteen  miles,  and,  according  to  the  ofiicial  report  of  the  Mississippi 
State  Geological  Survey,  "follows  the  eastward  curve  of  the  Delta  margin 
from  Memphis  to  Vicksburg,  then  southward  hugs  the  east  bank  of  the 
Mississippi  River  to  the  Louisiana  line.  The  region  bordering  imme- 
diately on  the  Mississippi  River  is  low-lying  and  in  sections  very  poorly 
drained.     An  admirable  descriptive  account  of  the  local  topographic 

*Report  on  Belzoni  drainage  district  in  Washington  County,  Miss.,  1912,  U.  S.  Agricultural  Experiment 
Stations  Bulletin  No.  Mi,  A  Report  upon  the  Drainage  of  the  Agricultural  Lands  of  Bolivar  County,  Missis- 
sippi, 1909,  U.  S.  Agricultural  Experiment  Stations  Circular  No.  81. 

fOf  special  interest  are  the  Soil  Surveys  for  the  Yazoo  Area,  by  Jay  A.  Bonsteel  and  Party,  reprinted  from 
the  Report  on  Field  Operations  of  the  Bureau  of  Soils  for  1901,  and  the  Soil  Survey  of  the  Smedes  Area  by 
Smith  and  Carter,  included  in  the  report  for  1902.  See,  also,  a  most  interesting  Report  on  Holmes  County, 
by  Geib,  in  the  Annual  Report  tor  1908,  and  on  Grenada  County  by  Tharp  and  Hogan  in  the  Report  for  1915. 

24 


features  has  been  made  available  through  the  Soil  Surveys  of  Adams  and 
Wilkinson  Counties.* 

Section  III. — Interior  Plateau  Counties  (twenty -five),  containing  an 
approximate  area  of  14,607  square  miles  and  a  total  population  of 
544,989  for  the  census  year  1910.  This  large  area  includes  varying 
topographic  and  geological  surface  features.  It  occupies  most  of  the 
central  portion  of  the  State  east  of  the  bluff  formation  bordering  on  the 
Delta  counties  and  north  of  a  line  running  approximately  from  Vicks- 
burg  to  thirty-five  miles  south  of  Meridian.  It  includes  a  portion  of  the 
so-called  "Black  Prairie  Belt,"  with  a  surface  not  only  nearly  level,  but 
consisting  of  "open  prairies  almost  devoid  of  tree  growth.  The  soils  are 
black  calcareous  clay  loams,  that  do  not,  in  the  flatter  areas,  drain  per- 
fectly, but  are  very  strong  and  productive.  Throughout  the  region  are 
areas  of  gentle  elevation."  The  main  portion  of  this  area,  however,  is 
represented  by  the  North  Central  Plateau,  "which  embraces  all  that  por- 
tion of  North  Central  Mississippi  lying  between  the  Flatwoods  on  the 
east  and  the  bluffs  overlooking  the  Delta  on  the  west,  and  extending 
from  the  border  of  Tennessee  south  to  a  line  drawn  approximately  from 
Canton  to  Meridian."  The  characteristic  soil  of  this  area  "is  a  yellow- 
ish-brown loam  containing  a  considerable  proportion  of  silt  and  clay." 
Another  but  small  area  included  is  the  so-called  "Jackson  Prairie  Belt."t 

Section  IV. —  Northeastern  Hill  Counties  (fourteen),  containing  an 
approximate  area  of  6,869  square  miles  and  a  total  population  of 
302,002  for  the  census  year  1910.  This  area  includes  the  so-called 
"Tennessee  River  Hills,"  which  occupy  the  two  extreme  northeastern 
counties  of  the  State  and  adjacent  parts  of  those  counties  bordering 
them  on  the  west  and  south,  which  "is  a  region  of  considerable  elevation 
and  rough  topography."  The  soils  of  the  hills  are  thin,  red  sandy  and 
pebbly  loams;  those  of  the  bottoms  are  rich  black  sandy  loams.  Accord- 
ing to  the  official  report  of  the  Mississippi  State  Geological  Survey, 
"the  geological  formations  of  this  region  are  the  indurated  limestones, 
sandstones  and  chert  beds  of  the  Paleozoic  Era,  overlapping  whose 
western  and  southern  borders  are  the  loose  sands,  clays  and  gravels  of  the 
Tuscaloosa  and  Eutaw  of  the  Cretaceous."  Included  in  this  section  is 
also  a  portion  of  the  Pontotoc  Ridge  region,  which,  as  its  name  indicates, 

*Soil  Survey  of  Adams  County,  Mississippi,  by  W.  J.  Geib,  of  the  U.  S.  Department  of  Agriculture,  and 
A.  L.  Goodman,  of  the  Mississippi  Geological  Survey,  Washington,  1911,  Soil  Survey  of  Wilkinson  County, 
Mississippi,  by  W.  E.  Tharp,  of  the  U.  S.  Department  of  Agriculture,  and  W.  M.  Spann,  of  the  Mississippi 
Geological  Survey,  Washington,  1915. 

tSoil  surveys  typical  of  this  area  are  the  one  for  Winston  County,  by  Crabb  and  Hightower,  published  in 
the  Report  on  Field  Operations  of  the  Bureau  of  Soils  for  1912,  and  the  one  for  Montgomery  County,  by  Caine 
and  Schroeder  for  1906. 

25 


is  "another  region  of  high  lands,  bordering  upon  the  west  side  of  the 
northern  half  of  the  Black  Prairies."  The  elevation  of  this  region 
probably  averages  more  than  five  hundred  feet.  The  soil  is,  on  the  whole, 
a  red  sandy  loam,  derived  from  the  weathering  of  the  sands  and  marls  of 
the  Ripley  formation.* 

Section  V. — Southern  Long- Leaf- Pine  Hill  Counties  (twenty-five), 
containing  an  approximate  area  of  14,513  square  miles  and  a  total 
population  of  465,208  for  the  census  year  1910.  This  region  occupies 
practically  the  whole  southern  half  of  Mississippi  south  of  Jackson  and 
extends  to  the  Gulf,  representing  practically  a  topographic  unit,  al- 
though subject  to  important  variations  in  matters  of  minor  physio- 
graphic detail.  According  to  the  Mississippi  State  Geological  Survey, 
"It  slopes  gently  from  an  altitude  of  more  than  four  hundred  feet  at  its 
northern  border  to  sea-level  at  the  Gulf."  The  soils  are  "red  and  yellow 
sandy  loams,  derived  from  the  Pliocene,  which  is  the  prevailing  surface 
formation  east  of  the  Pearl  River.  In  the  higher  regions  farther  west 
the  brown  loam  overlies  the  Pliocene  to  a  great  extent."  The  general 
surface  of  this  region,  "like  that  of  its  prototype  farther  north,  is 
naturally  dissected  giving  it  an  uneven  topography,  in  which  there  are 
large  areas  of  gently  rolling  or  nearly  level  land."  The  chief  feature  of 
the  whole  region  is  the  extensive  forests  of  long-leaf  pine,  which  origi- 
nally covered  its  surface  in  one  unbroken  expanse,  t  It  is  of  interest  in 
this  connection  that  it  is  in  this  section  that  the  cantonment  of  Camp 
Shelby  is  located,  in  the  vicinity  of  Hattiesburg  County.  { 

GEOGRAPHICAL  DISTRIBUTION  IN  MISSISSIPPI 

In  the  table  following  the  malaria  morbidity  and  mortality  according 
to  race  has  been  correlated  to  the  foregoing  approximate  physiographic 
divisions  of  the  State  of  Mississippi.  Since,  unfortunately,  the  county 
boundary  lines  do  not  coincide  with  the  more  important  topographic 
surface  features,  the  correlation,  of  course,  cannot  possibly  be  made  in 
precise  conformity  to  the  physiographic  facts.  The  table,  however, 
will  s.erve  tiie  practical  purpose  of  emphasizing,  on  the  one  hajid,  the 

*A  Report  on  the  Soil  Survey  of  Pontotoc  County,  by  Bennett  and  Winston,  was  included  in  the  Report 
of  the  Field  Operations  of  the  Bureau  of  Soils  for  1906. 

fThe  widely  varying  soil  conditions  of  this  xtensive  area  are  described  in  the  Soil  Survey  of  Wayne  County, 
by  Goodman  and  Jones,  included  in  the  Report  of  the  Field  Operations  of  the  Bureau  of  Soils  for  1911,  the 
Soil  Survey  of  the  Scranton  Area,  by  Lee,  Allen  and  Winston,  in  the  Report  for  1909,  the  Soil  Survey  of  the 
Forrest  County  Area,  by  Tharp  and  Spann,  in  the  Report  for  1911,  and  the  Soil  Survey  of  the  McNeill  Area,  by 
Smith  and  Carter,  in  the  Report  for  1904. 

JAccording  to  the  report  of  the  Surgeon-General  of  the  U.  S.  Public  Health  Service,  the  number  of  cases  of 
malaria  in  the  Hattiesburg  district  during  the  year  1916  was  2,049,  which,  on  an  estimated  civil  population  of 
only  16,482,  is  equivalent  to  a  malaria  morbidity  rate  of  124.3  per  1,000. 

26 


Mortality  Rate  per 
100,000  Population 

White 

COLOBED 

170.8 

141.4 

76.9 

110.9 

58.5 

77.5 

38.9 

62.0 

34.3 

45.8 

far-reaching  utility  of  intensive  studies  of  malarial  frequency  with 
reference  to  surface  features  and,  on  the  other,  the  approximate  con- 
clusiveness of  the  available  data  as  an  aid  in  the  geographical  study  of 
the  disease.* 

MORBIDITY  AND  MORTALITY  FROM  MALARIA  IN 
MISSISSIPPI,  1915-1916 

y~,       .     /-,  Morbidity  Rate  per 

County  Group  1  000  Population 

White  Colored 

Delta  Counties 247.7  135.0 

Southern  River  Counties 118.0  69.7 

Interior  Plateau  Counties 70.5  56.6 

Northeastern  Hill  Counties ....  54.8  34.9 

Southern  Pine  Counties 66.2  53.3 


MALARIA  IN  THE  YAZOO  DELTA 

The  table  reemphasizes  the  well-known  fact  that  the  Delta  Counties 
are  still  an  intensely  malarial  region,  regardless  of  the  commendable  and 
considerable  progress  which  has  been  made  in  the  reduction  of  malaria 
frequency  in  this  region  during  the  last  twenty  years.  The  contrast 
between  the  malaria  intensity  in  this  section  and  that  of  the  region 
described  as  the  Northeastern  Hill  Counties  is  very  marked.  In  course 
of  time,  when  the  statistics  are  available  for  a  longer  period  of  years,  the 
conclusions  regarding  each  and  every  county  will,  of  course,  be  more 
trustworthy.  It  has  therefore  not  seemed  advisable  to  enlarge  upon 
these  aspects  of  the  malaria  question  in  Mississippi  at  the  present  time 
further  than  that  in  the  table  following  the  malaria  morbidity  and  mor- 
tality rates  by  race  for  the  two  years  1915-1916  are  separately  given 

•The  Medico-Actuarial  Investigation  with  reference  to  the  relation  of  mortality  to  location  has  brought 
to  light  much  interesting  and  important  information.  The  facts,  however,  are  rather  too  technical  for  an 
abbreviated  discussion.  The  information  on  the  mortality  of  the  Southern  States  is  contained  in  Volume  V, 
issued  in  1914.  Among  other  interesting  results  it,  for  illustration,  is  shown  that  in  the  Delta  counties  only  the 
ratio  of  actual  to  expected  deaths  was  160  per  cent,  among  male  applicants  who  had  had  an  attack  within  two 
years  of  application  and  159  per  cent,  among  applicants  who  had  had  one  attack  more  than  two  years  prior  to 
application  or  at  an  indefinite  time  in  the  past.  In  the  other  counties  of  the  area  under  consideration  the  ratio 
of  actual  to  ejfpected  deaths  was  144  per  cent,  for  applicants  who  had  suffered  one  attack  within  two  years  of 
application  and  113  per  cent,  for  applicants  who  had  suffered  one  attack  between  two  and  ten  years  prior  to 
application.  In  general,  the  mortality  in  the  Delta  counties  of  Arkansas  and  Mississippi  was  about  30  per  cent, 
greater  than  in  the  other  counties.  It  is  said  further  in  the  report  that  "The  fourteen  companies  which  contrib- 
uted their  Southern  States'  data  experienced  in  the  Delta  Counties  of  Mississippi  and  Arkansas  on  all  their  busi- 
ness (including  cases  with  a  history  of  malaria)  a  mortality  of  180  per  cent.,  a  higher  mortality  than  among  the 
cases  with  a  history  of  malaria  in  the  forty-three  companies.  In  the  counties  of  Mississippi  and  Arkansas  other 
than  Delta  Counties,  the  mortality  of  the  fourteen  companies  on  all  their  business  was  134  per  cent,  against 
126  per  cent,  in  the  forty-three  companies  for  the  insured  with  a  history  of  one  attack  of  malarial  fever." 

27 


for  each  of  the  twelve  Delta  Counties  which  constitute  the  so-called 
"Yazoo  Delta"  region.* 


Morbidity  Bate  per 
1,000  Population 


MALARIA  IN  THE  DELTA  COUNTIES  OF 

1915-1916 

County 

White  Colored 

Bolivar 357.2  159.1 

Coahoma 336.2  179.0 

Holmes 236.7  145.0 

Issaauena 248.2  53.8 

Leflore 206.9  127.8 

Quitman 178.2  76.0 

Sharkey 198.6  66.1 

Sunflower 445.6  218.1 

Tallahatchie 99.6  89.9 

Tunica 332.5  128.4 

Washington 213.6  109.5 

Yazoo 235.2  124.8 


MISSISSIPPI 


Mortality  Rate  per 
100,000  Population 


White 

131.5 

148.1 

95.8 

61.0 

91.0 

262.1 

216.3 

446.4 

208.3 

144.1 

131.1 

134.7 


Colored 

156.0 
227.6 
116.4 
178.1 
113.2 
132.1 
45.0 
153.8 
134.1 
152.1 
121.3 
137.8 


ERADICATION  MEASURES  IN  BOLIVAR  COUNTY 
MISSISSIPPI 

This  table  is  of  special  importance  in  view  of  the  rather  promising 
malaria  eradication  work  carried  on  by  the  Interhational  Health  Board  in 
Bolivar  County,  which  may  be  considered  typical  of  the  Yazoo  Delta 
region.  Unfortunately,  no  soil  survey  has  as  yet  been  published  for  this 
county,  but  one  is  available  for  the  adjoining  county  of  Coahoma,  which 
represents  approximately  similar  physiographic,  geological  and  soil 
conditions,  t  The  work  of  the  International  Health  Board  is  limited  to 
the  eastern  half  of  Bolivar  County,  containing  an  approximate  area  of 
225  square  miles  and  an  estimated  population  of  1,924  white  and  12,325 
colored.  It  requires  to  be  said  in  this  connection  that  the  International 
Health  Board  of  the  Rockefeller  Foundation  carried  on  four  experiments 
in  malaria  control  during  1916  at  different  points  in  the  lower  Mississippi 
Valley.     According  to  the  annual  report  of  the  Foundation  for  1916, 

*It  is  most  regrettable  that  the  boundary  lines  of  the  Delta  Counties  should  not  be  more  in  conformity  to  the 
peculiar  topography.  Of  a  number  of  the  counties  only  a  relatively  small  portion  of  the  area  is  strictly  within 
the  Delta,  making  an  exact  definition  of  the  Delta  area,  as  a  whole,  in  accordance  with  county  boundary  lines 
impossible.     In  some  descriptive  definitions  certain  counties  are  included  which  are  excluded  in  others. 

fSoil  Survey  of  Coahoma  County,  Mississippi,  by  F.  Z.  Button,  in  charge,  W.  E.  Tharp,  N.  M.  Kirk  and 
H.  W.  Hawker,  of  the  U.  S.  Department  of  Agriculture,  and  E.  M.  Jones,  of  the  Mississippi  Geological  Survey, 
Washington,  1916. 


28 


"In  each  a  different  line  of  investigation  was  pursued,  the  object  being  to 
discover  a  practical  method  of  control  which  the  average  rural  com- 
munity could  afford."  The  experiment  in  Bolivar  County  is  briefly 
described  as  follows: 

An  experiment  was  conducted  under  the  administration  of  the  Mississippi 
Department  of  Health,  with  Dr.  W.  S.  Leathers  as  Administrative  Director 
and  Dr.  C.  C.  Bass,  of  Tulane  University,  as  Scientific  Director.  The  practica- 
bihty  of  control  through  detecting  the  carriers  and  freeing  them  of  the  malaria 
parasites,  was  tested.  The  experiment  covered  two  hundred  twenty-five  square 
miles  of  territory,  the  size  of  the  communities  varying  from  nine  to  sixteen  square 
miles,  with  an  average  population  of  one  thousand.  Adjoining  communities 
were  taken  up  one  after  another  as  facilities  permitted,  the  work  in  each  lasting 
about  four  weeks,  with  subsequent  visits  to  insure  thoroughness.  Blood  tests 
were  taken.     Quinine  treatment  was  given  to  those  found  infected. 

The  experiment  was  continued  during  1917  and  will  probably  be 
carried  forward  for  several  years  to  come.  The  area  of  operations  will, 
if  possible,  be  extended  to  two  or  three  adjoining  counties  which  have 
given  official  assurances  of  financial  cooperation. 

QUININE  PROPHYLAXIS 

A  full  account  has  not  as  yet  been  made  public  by  the  International 
Health  Board  regarding  the  precise  methods  and  attained  results  of 
this  exceptionally  interesting  experiment  in  malaria  control.  The 
evidence  of  such  control  must  naturally  be  more  or  less  of  a  statistical 
nature.  According  to  a  statement  furnished  by  the  Board  there  has 
been  a  very  marked  reduction  in  the  percentage  of  positive  findings  in 
the  blood  specimens  examined  during  the  year  1917  compared,  weekly, 
with  the  corresponding  results  for  the  previous  year.  Thus,  for  illustra- 
tion, during  the  week  ending  September  16,  749  blood  specimens  were 
examined  in  Bolivar  County,  of  which  535  were  positive,  or  71.4  per 
cent.  During  the  corresponding  week  of  1917  the  number  of  specimens 
examined  was  950,  of  which  only  152  were  positive,  or  16  per  cent. 
It,  however,  is  not  at  all  certain  whether  identical  persons  were  examined; 
in  fact,  it  is  safe  to  assume  that  this  ,was  not  the  case.  Nor  is  it  certain 
whether  identical  areas  were  considered,  but,  quite  to  the  contrary,  the 
comparison  is  merely  for  blood  counts  at  random,  and  the  results  are 
not,  therefore,  strictly  comparable,  though  in  a  general  way  they,  no 
doubt,  justify  the  conclusion  of  a  marked  reduction  in  the  prevailing 
degree  of  malarial  infection  as  ascertainable  by  the  microscopical  ex- 
amination of  the  blood.  To  be  strictly  comparable,  the  results  should 
be  for  identical  persons  and  identical  areas,  since  the  investigations 


thus  far  made  indicate  a  surprising  degree  of  variation  in  the  intensity  of 
infection  in  the  more  than  thirty  different  communities  or  units  into 
which  the  field  of  operations  has  been  divided. 

MALARIA  MORBIDITY  OF  BOLIVAR  COUNTY 

At  the  outset  of  the  investigation  a  blood  index  was  secured  for  the 
entire  population  under  control.*  There  has,  however,  not  been  a 
corresponding  complete  reexamination.  Considering  the  fact  that 
most  of  the  population  is  colored  and  that  many  have  moved  away, 
while  others  have  come  into  the  area,  the  task  of  precise  comparison  of 
results  is  possibly  a  hopeless  one.  The  same  conclusion  may  ultimately 
apply  to  the  broader  question  of  individual  control,  both  as  regards 
proper  quinine  treatment  and  the  reexamination  of  the  blood.  It 
would  therefore  be  premature  to  express  an  opinion  upon  this  interesting 
experiment  until  an  oflBcial  report  is  forthcoming,  which,  it  is  to  be  hoped, 
will  include  a  complete  analysis  of  all  the  data  secured  during  the  period 
from  the  commencement  of  the  experiment  to  the  present  time. 
One  interesting  statistical  statement,  however,  may  here  be  introduced, 
which  being  derived  from  other  sources  has  a  direct  bearing  upon  the 
question  under  consideration.  The  following  table  shows  the  compar- 
ative frequency  of  malaria  in  Bolivar  County  during  the  first  ten  months 
of  1916  and  of  1917: 

COMPARATIVE  FREQUENCY  OF  MALARIA  IN  BOLIVAR 

COUNTY,  MISS. 

(First  ten  months  of  1916  and  of  1917) 

White  Colored  Total 

1916 2,335  7,361  9,696 

1917 2,593  7,215  9,808 

Increase 258                           112 

Decrease 146  .... 

MALARIA  MORBIDITY  OF  WASHINGTON  COUNTY 

According  to  this  table  there  was  an  actual  increase  in  the  number  of 
reported  cases  of  malaria  in  Bolivar  County  among  the  white  popula- 
tion of  258,  whereas  there  was  a  decrease  of  146  cases  among  the  colored. 

*The  word  "control"  is  used  in  a  very  general  sense.  Actually,  of  course,  the  control  exercised  over  the 
population  is  very  limited.  About  the  best  and  the  most  that  can  be  done  is  to  persuade  employers  of  labor 
to  give  preference  to  those  who  habitually  take  quinine  as  a  precaution  against  economic  loss.  The  scarcity 
of  the  labor  supply,  however,  precludes  a  far-reaching  effect  of  such  cooperation  on  the  part  of  the  employers. 
The  difficulty  with  the  negro  is  that  he  cannot  be  relied  upon  to  keep  his  promises  and  that  his  statements  with 
reference  to  the  actual  taking  of  quinine  require  to  be  accepted  with  reserve. 

30 


Relatively  speaking,  the  malaria  frequency  in  the  county  as  a  whole 
remained  practically  unchanged,  regardless  of  the  eradication  efforts 
by  quinine  immunization  alone.  The  fact,  of  course,  must  not  be  over- 
looked that  the  work  heretofore  has  been  limited  to  only  one-half  of  the 
county,  and  that  there  is  a  possibility  that  cases  of  malaria  were  better 
reported  during  1917  than  during  1916,  but  the  conclusion  remains 
unchanged  that  in  so  far  as  the  official  returns  can  be  relied  upon  there 
were  9,808  cases  of  malaria  in  Bolivar  County  during  the  first  ten  months 
of  1917,  although  the  experimental  work  or  efforts  at  control  by  means 
of  immunization  by  doses  of  quinine*  had  been  applied  in  the  case  of 
nearly  half  of  the  population  for  nearly  three  years.  If  these  statistics 
are  untrustworthy,  they  should  be  subjected  to  a  critical  examination  by 
those  directly  concerned  with  the  public  viewpoint  of  the  experiment  or 
administration  work  in  Bolivar  County.  They  are  the  official  data  of 
the  State  Board  of  Health,  the  director  of  which  is  also  the  State  Director 
of  the  malaria  eradication  measures  of  the  International  Health  Board 
in  Bolivar  County.  For  purposes  of  comparison  a  table  is  here  included 
for  the  adjoining  county  of  Washington,  in  which  no  such  eradication 
efforts  have  been  carried  on,  but  in  which,  nevertheless,  there  was  an 
actual  decrease  in  malaria  frequency  among  both  elements  of  the 
population  of  1,205  cases,  or  a  reduction  from  5,273  cases  during  the 
first  ten  months  of  1916  to  4,068  during  the  same  period  of  1917. 

COMPARATIVE  FREQUENCY  OF  MALARIA  IN  WASHINGTON 
COUNTY,  MISSISSIPPI 

(First  Ten  Months  of  1916  and  of  1917) 

White  Colored  Total 

1916 1,354  3,910  5,273 

1917 1,152  2,916  4,068 

Increase ....  .... 

Decrease 202  1,003  1,205 

ERADICATION  MEASURES  IN  ASHLEY  COUNTY,  ARKANSAS 

Aside  from  the  experiment  or  demonstration  in  Bolivar  County,  the 
International  Health  Board  has  also  carried  on  some  very  interesting 
work  at  Lake  Village  and  Crossett,  in  the  adjoining  State  of  Arkansas, 
in  cooperation  with  the  United  States  Public  Health  Service,  originally 

*The  dose  required  is  ten  grains  a  day  for  eight  weeks  in  the  case  of  adults,  but  half  a  grain  for  every  year  of 
life  under  twenty.  Originally  the  dose  recommended  was  required  to  be  taken  for  four  weeks  only,  but  this 
period  was  found  to  be  too  short. 

31 


under  the  general  supervision  of  the  late  Dr.  R.  H.  von  Ezdorf.  This 
work  was  subsequently  transferred  to  Dr.  H.  A.  Taylor,  of  the  Inter- 
national Health  Board,  and  Assistant  Surgeon  R.  C.  Derivaux,  of  the 
United  States  Public  Health  Service.  The  work  at  Crossett,  which  is 
of  the  first  importance,  is  briefly  described  in  the  annual  report  of  the 
Rockefeller  Foundation  for  1916,  in  part,  as  follows: 

The  experiment  at  Crossett  was  based  on  mosquito  control  without  major 
drainage  operations.  The  work  consisted  of  the  draining  and  regrading  of 
natural  streams  so  as  to  secure  rapid  off-flow,  the  filUng  of  bottoms,  the  digging 
of  ditches,  the  removal  of  accumulated  vegetation,  and  the  systematic  use  of 
oil  and  other  larvacidal  substances  by  sprays  and  automatic  drips.  A  remark- 
able decrease  in  the  number  of  malaria  caUs  resulted.  During  the  last  six 
months  of  1915  there  were  2,100  malaria  calls  in  Crossett;  during  the  last  six 
months  of  1916,  510  calls.  In  October,  1915,  there  were  600  calls;  in  October, 
1916,  46  calls.  In  December,  1915,  there  were  100  calls;  in  December,  1916, 
the  malaria  index  had  been  brought  far  below  the  normal  winter  level  and  was 
approaching  the  zero  point.  As  a  result  of  the  steady  decrease  in  malaria  cases, 
community  interest  in  Crossett  was  aroused  to  take  over  the  work  for  1917, 
with  a  view  to  making  it  permanent.  A  similar  experiment  was  also  under- 
taken and  is  now  in  progress  at  Hamburg,  Arkansas. 

This  work  has  since  been  reported  upon  in  considerable  detail  by  the 
Pubic  Health  Service  in  a  Bulletin  on  "Malaria  Control:  A  Report  of 
Demonstration  Studies  Conducted  in  Urban  and  Rural  Sections."* 
It  may  be  questioned  whether  a  more  important  contribution  to  the 
practical  question  of  malaria  control  in  the  Southern  States  has  ever 
been  mad,e,  or  is  likely  to  be  made  in  the  near  future.  The  results  are 
such  as  to  justify  the  conclusion  that  the  procedure  adopted  was  in 
conformity  to  the  most  practical  and  permanently  successful  methods 
of  eradication  and  control,  with  a  due  regard,  of  course,  to  local  condi- 
tions, of  which  it  may  be  said  that  in  the  main  they  were  free  from 
serious  engineering  or  other  difficulties.  The  town  of  Crossett  is  a  model 
community  owned  entirely  by  a  lumber  company,  f  accurately  laid  out 
and  occupying  an  area  measuring  about  one-half  by  one  mile.  Eradi- 
cation efforts  are  invariably  more  successful  where  the  area  under 

•For  a  brief  descriptive  account  of  the  activities  of  the  U.  S.  Public  Health  Service  in  connection  with 
Malaria  Administration  and  Control  Work,  see  the  annual  report  of  Surgeon-General  Rupert  Blue  for  the 
fiscal  year  1917,  p.  18,  et  seq.  Of  special  interest  is  a  statement  of  malaria  index  determination  since  July,  1916, 
according  to  which  out  of  4,116  persons  examined,  254,  or  6.19  per  cent.,  were  positive  as  to  the  presence  of  the 
malarial  parasite  in  the  blood.  The  proportion  was  highest  for  Greenville,  Miss.,  or  21.65,  and  next  highest 
for  Franklin,  Va.,  or  11.76  per  cent.  Reports  of  cases  of  hemoglobinuria  fevers  were  received  from  physicians 
in  Alabama,  Arkansas,  Florida,  Louisiana,  North  Carolina,  South  Carolina,  Tennessee  and  Texas.  See,  also. 
Reprint  No.  443,  "Extra-Cantonment  Zone  Sanitation,"  Washington,  1918. 

tPublic  Health  Bulletin  No.  88,  September,  1917,  "Malaria  Control:  A  Report  of  Demonstration  Studies 
Conducted  in  Urban  and  Rural  Sections,"  by  R.  C.  Derivaux,  Assistant  Surgeon,  U.  S.  Public  Health  Service, 
and  H.  A.  Taylor  and  T.  D.  Haas,  Field  Directors,  Washington,  1917. 

32 


control  is  relatively  limited  in  extent.*  The  population  of  Crossett  was 
2,029,  and  the  measures,  directed  chiefly  against  mosquito  production, 
consisted  of  clearing,  draining,  filling  and  the  use  of  oil  and  larvacides. 
According  to  the  report  made  jointly  by  Drs.  Derivaux,  Taylor  and 
Haas,  "As  ascertained  by  repeated  parasite  indices,  a  reduction  of  77.33 
per  cent,  was  obtained,  and  a  reduction  of  the  total  visits  for  malaria,  as 
compared  with  records  of  the  previous  year,  of  70.39  per  cent.  For  the 
'active'  season,  comprising  the  months  from  and  including  June  to 
December,  a  reduction  of  visits  of  82.07  per  cent,  was  obtained  from  the 
number  made  in  the  same  period  of  the  year  before.  The  total  costs  of 
the  control  operations  aggregate  $2,506.40,  a  per-capita  cost  of  $1.23; 
control  work  is  to  be  continued,  and,  much  of  the  first  work  being  of  a 
permanent  character,  should  cost  substantially  less." 

ERADICATION  MEASURES  IN  CHICOT  COUNTY,  ARKANSAS 

In  the  nearby  rural  community  of  Lake  Village,  Chicot  County,  the 
same  well-considered  method  of  eradication  was  pursued,  and  studies 
of  the  efficacy  of  house-screening  and  of  quinine-immunizing  and  steril- 
izing doses  were  conducted.  It  is  said  in  the  report  that  "A  group  of 
thirty-three  houses  was  carefully  screened  at  an  average  cost  of  $14.77, 
and  their  occupants  carefully  observed,  all  known  carriers  being  given  qui- 
nine for  sterilization.  As  shown  by  repeated  parasite  indexes,  a  reduction 
of  70.6  was  obtained  among  142  occupants;  as  the  life  of  the  screening 
installed  should,  with  ordinary  care,  be  at  least  two  years,  the  per-family 
cost  of  screening  is  estimated  at  $7.38  per  family,  or  $1.75  per  capita." 

In  further  explanation  of  the  experiment  in  Chicot  County,  it  is 
stated  that  "In  a  second  series,  quinine  was  given  to  237  persons  for 
immunization,  and  a  reduction  in  malaria  of  64.45  per  cent,  was  obtained 
as  ascertained  by  repeated  parasite  index  examination;  the  per-capita 
cost  for  quinine  issued  was  $0.57.  Of  the  sixty-nine  carriers  to  whom 
quinine  was  given  for  sterilization,  sixty-two  remained  under  observa- 
tion and  were  available  for  reexamination;  of  this  latter  number,  three 
were  found  to  have  remained  infected,  a  reduction  or  'sterilization'  rate 
of  95.17  per  cent.  The  economic  losses  suffered  by  a  negative  group  of 
120  persons  averaged  $11.21  per  family,  or  $2.52  per  capita,  whereas 
among  the  members  of  the  groups  under  control  the  family  loss  averaged 
$0.23,  and  that  per  capita  $0.06."     These  control  experiments,  as  will 

•The  measures  employed  at  Crossett  for  the  control  of  malaria,  according  to  Bulletin  No.  88,  "consisted  ex- 
clusively of  procedures  directed  against  mosquito  propagation,  and  have  included  drainage,  clearing  and 
training  of  streams,  and  control  of  artificial  containers,  etc.,  over  an  area  about  one  half-mile  square." 

33 


be  noted,  relate  to  only  a  relatively  small  population.  In  the  Bolivar 
County  experiments,  it  may  be  said,  in  this  connection,  the  population 
under  control,  or  attempted  control,  numbered  4,734  white  and  20,303 
colored.* 

ENTOMOLOGICAL  INVESTIGATIONS  IN  LOUISIANA 

The  experiments  referred  to  are  among  the  most  encouraging  present- 
day  eflForts  in  this  country  to  establish  community  measures  of  control 
with  a  due  regard  to  social  and  economic  considerations.  Possibly  of 
even  greater  scientific  interest,  however,  in  the  broader  sense,  is  the 
remarkable  work  of  the  United  States  Bureau  of  Entomology  at  Mound, 
La.,  under  the  direction  of  Mr.  (now  Lieutenant)  D.  L.  VanDine. 
This  experiment  has  been  described  with  reasonable  thoroughness  in 
an  article  in  the  Scientific  Monthly  of  November,  1916.  f  The  funda- 
mental object  which  underlies  the  investigation  is  to  secure  definite 
data  on  the  manner  in  which  malaria  affects  agriculture,  or,  in  other 
words,  the  underlying  considerations  are  economic  rather  than  medical 
or  remedial.  The  experiment  includes  an  entire  plantation,  admirably 
situated  for  such  a  purpose,  on  the  west  side  of  the  Mississippi  River, 
almost  opposite  the  city  of  Vicksburg.  f  Perfect  cooperation  has  been 
secured  between  the  principal  owner  of  the  plantation,  Mr.  George  S. 
Yerger,  the  physician  in  charge.  Dr.  Wm.  P.  Yerger,  and  the  micro- 
scopical and  entomological  control  through  Messrs.  W.  V.  King  and  J. 
K.  Thibault,  Jr.  During  the  season  of  1914  the  survey  work  included 
a  detailed  study  of  74  tenant  families,  who  cultivated  1,800  acres  of  land, 
of  which  1,191  acres  were  under  a  tenant  system  and  609  acres  under 
the  direct  supervision  of  the  plantation  management  by  labor  drawn 
from  the  tenant  families  on  a  day-wage  basis.  "The  tenants  averaged  16 
acres  per  family,  and  the  74  families  included  a  total  of  299  individuals. 
The  crops  grown  consisted  of  743  acres  of  cotton  and  448  acres  of  corn 
under  the  tenant  system  and  80  acres  of  cotton  and  209  acres  of 
corn,  200  acres  of  oats,  70  acres  of  cow-peas  and  50  acres  of  lespedeza 
hay  under  the  day-wage  system.  All  time  was  reduced  to  adult  time, 
or  man  days  of  labor.  The  time  of  a  male  over  eighteen  years  of  age 
was  figured  as  full  time,  a  male  from  twelve  to  eighteen  years  as  one- 
half  adult  time,  and  from  eight  to  twelve  years  as  one-fourth.  The 
time  of  a  female  was  figured  as  one-half  the  time  of  a  male.     Reducing 

•U.  S.  Public  Health  Bulletin  No.  88  on  Malaria  Control,  p.  55. 

fAnother  discussion  on  the  loses  to  rural  industries  through  mosquitoes  that  convey  malaria,  by  Mr.  D.  L. 
VanDine,  occurs  in  The  Southern  Medical  Journal,  for  March,  1915. 

{The  topography  of  this  locality  is  precisely  shown  on  the  topographic  atlas  sheet  of  Louisiana  (Madison 
Parish),  Mound  Quadrangle,  issued  by  the  U.  S.  Geological  Survey  in  1910. 

34 


all  the  available  labor  on  the  plantation  to  adult  time,  the  resulting 
equivalent  labor  was  two  adults  to  each  of  the  seventy-four  tenant 
families.  The  actual  time  lost  through  malaria  consisted  of  970  days 
for  those  treated  by  the  plantation  physician,  487  days  representing 
cases  not  reported  to  the  physician  and  385  days  lost  by  non-malarial 
members  of  the  families  in  attending  those  who  had  the  disease. 
There  was  a  total  loss  of  1,842  days,  which,  reduced  to  adult  time,  and 
not  taking  account  of  illness  in  members  of  the  families  under  eight 
years  of  age,  amounted  to  1,066  days  of  adult  time,  from  May  to  Octo- 
ber, inclusive.  The  time  lost  averaged  14.4  adult  days  for  each  family. 
There  were  166  cases  of  malaria  in  138  persons  out  of  a  total  of  299 
members  of  the  tenant  families.  There  was  a  loss  of  time  equivalent 
to  6.42  adult  days  for  each  case  of  malaria." 

RELATION  TO  CROP-PRODUCTION 

In  further  explanation,  it  is  said  in  the  article  referred  to  that  "The 
effect  of  loss  of  time  upon  the  crops  can  be  measured  by  the  ratio  of 
the  time  lost  through  malaria  to  the  difference  between  the  available 
labor  and  labor  requirements  of  the  crops.  It  must  be  conceded  that 
any  loss  of  labor  from  any  cause  in  the  face  of  any  surplus  labor  that 
exceeds  the  time  lost  cannot  be  considered  as  operating  against  the 
crops.  In  the  case  of  no  surplus  labor  or  an  actual  deficiency,  any  time 
lost  through  malaria  reacts  at  once  upon  the  crops,  the  seriousness  of  the 
neglect  to  the  crops  depending  upon  the  period  in  the  planting,  cultivat- 
ing or  harvesting  the  crops  that  the  lost  time  occurs.  It  will  he  shown 
that  time  lost  through  malaria  during  at  least  four  months  of  the  year  falls 
at  a  period  when  there  is  a  deficiency  of  labor  and  when  the  demands  of  the 
crops  for  labor  are  greatest.  For  cotton,  the  principal  crop,  these  periods 
are  chopping,  and  hoeing,  boll -weevil  control  and  picking.  Any  neglect 
at  these  periods  is  a  very  serious  matter  and  might  mean  total  failure  of 
a  crop."  Without  enlarging  upon  the  evidence  subsequently  presented 
by  Mr.  VanDine  in  considerable  detail,  it  is  sufficient  for  the  present 
purpose  to  merely  give  the  general  conclusion:  "Each  family  culti- 
vated an  average  of  16  acres.  The  plantation  depended  upon  the 
tenants  for  labor  to  cultivate  an  average  of  8.23  acres  each  on  the  day- 
wage  basis.  This  amounted  to  a  total  of  24.23  acres  to  be  cultivated  by 
the  labor  represented  in  each  tenant  family,  and  equivalent  to  13.51 
acres  of  cotton.  The  total  loss  of  time  of  13.79  families  is  equivalent 
to  that  of  the  total  crop  on  186.3  acres  of  cotton.  With  an  average 
yield  of  one-half  of  a  bale  of  cotton  per  acre,  this  would  equal  a  total 

35 


loss  of  93.15  bales  of  cotton.     Allowing  $70  a  bale  for  the  lint  and  seed, 
this  would  amount  to  $6,520.50." 

RELATION  OF  CLIMATE  TO  INSECT  LIFE 

This  most  interesting  and  promising  experiment  is  still  in  progress. 
An  admirable  set  of  records  is  kept,  which  in  course  of  time  will  make  an 
extraordinary  amount  of  useful  and  conclusive  information  available. 
The  blood-examination  record,  in  part,  includes  such  additional  data  as 
the  recent  malaria  history,  the  recent  ingestion  of  quinine,  the  use  of 
chill  tonics,  the  question  of  medical  consultation,  the  final  diagnosis  and 
the  ultimate  termination  of  the  disease,  whether  recovery  or  death. 
Blood  smears  are  first  identified  and  then  referred  to  the  consulting 
expert  for  confirmation.  The  character  of  the  infection  is  noted;  also 
the  condition  of  the  blood,  and  a  reference  is  made  to  a  previous  infec- 
tion. In  addition  thereto,  an  exceptionally  complete  collection  has  been 
made  of  all  the  important  data  relating  to  mosquito  frequency,  including 
density,  direction  of  flight,  etc.  This  information  is  being  correlated  to 
an  admirable  set  of  climatological  observations.  The  only  important 
factor  omitted  is  the  wind  force,  which  must  be  considered  unfortunate. 
Careful  studies  have  been  made  of  the  labor  requirements  of  cotton- 
production,  as  to  both  periods  of  activity  and  quantity  in  correlation 
to  seasons  of  the  year.  Similar  studies  have  been  made  of  the  essential 
agricultural  requirements  in  the  production  of  corn  and  oats.  A  com- 
plete survey  is  made  of  every  house  and  family,  with  due  regard  to 
environmental  conditions  and  their  relation  to  mosquito  prevalence  and 
malaria.  Prophylactic  methods  in  force  are  taken  note  of,  and  a  de- 
scriptive account  is  kept  of  every  member  of  the  family  with  a  history 
of  malaria,  as  to  the  form  of  fever,  method  of  diagnosis,  duration,  treat- 
ment and  general  health.  A  history  chart  is  also  kept  of  other  diseases 
treated  by  the  physician,  as  a  matter  of  collateral  information.  Aside 
therefrom  is  a  statement  from  the  plantation  manager,  Mr.  Alexander 
Clark,  as  to  the  essential  economic  factors,  such  as  the  relation  of  the  fam- 
ily to  the  plantation,  the  length  of  residence,  the  value  of  the  land,  the  nor- 
mal return  per  acre,  the  present  return,  and,  finally,  the  estimated  losses 
due  to  various  causes.  A  record  is  kept  of  mosquito  collections,  of  blood 
specimens,  of  predacious  aquatic  insects,  of  fish,  of  water-plants,  also 
samples  of  soil,  etc.,  and,  finally,  a  summary  of  the  anopheles  collections, 
according  to  their  precise  determination  and  place  of  collection.  There 
is  also  kept  a  summary  of  economic  losses  (differentiating  the  loss  to  the 
plantation   and  the  loss  to  the  family),  loss  in  time,  labor-shortage, 

36 


land  lying  idle,  crop-shortage  and  decreased  eflBciency,  the  loss  to  the 
family  (differentiating  loss  of  time  through  malaria,  through  attendance 
on  patients,  through  crop-shortage,  through  medical  expenses  and  nurs- 
ing, general  ill  health  and  death).  The  meteorological  record  is  limited 
to  minimum  temperature,  humidity,  rainfall,  sunshine  or  cloudiness  and 
wind  direction.  The  information  accumulated  under  this  experiment 
constitutes,  as  far  as  known,  the  most  complete  collection  of  data  on 
malaria  in  its  social  and  economic  relations  extant.  If  carried  forward 
during  a  period  of  years,  the  data  should  prove  invaluable  in  connection 
with  every  future  study  of  the  disease.  There  is  the  additional  and  con- 
siderable advantage  of  complete  supervision  and  control  through  a  small 
group  of  men  thoroughly  interested  in  the  methods  of  the  investigation, 
but  free  from  any  bias  whatever  as  to  the  results.  It  is  an  investigation 
pure  and  simple,  and  not  an  attempt  to  prove  the  efficacy  of  one  method 
of  control  or  another.  It  admirably  reflects  the  far-sighted  policy  of  an 
important  government  department  deserving  of  wide  public  appreciation.* 

LAND  RECLAMATION  AND  DRAINAGE 

The  economic  aspects  of  malaria  are,  fortunately,  much  better  under- 
stood at  the  present  time  than  in  the  past.  As  evidence  of  progress  in 
this  direction,  mention  may  be  made  of  a  special  bulletin  issued  by  the 
United  States  Chamber  of  Commerce,  under  date  of  October  27,  1916, 
on  the  "Reclamation  of  Swamp  Lands  and  the  Conquest  of  the  Malaria- 
Bearing  Mosquito."     As  observed  in  this  bulletin, 

The  work  of  reclamation  of  any  moment  is  an  enterprise  of  comparatively 
recent  times,  but  grows  in  volume  and  importance  each  year.  It  is  practically 
all  done  by  private  enterprise,  sometimes  by  individuals,  sometimes  by  chartered 
companies,  but  more  often  by  cooperative  organizations  having  a  legal  status 
in  the  form  of  what  are  known  as  drainage  districts.  The  districts  are  formed 
usually  by  the  majority,  sometimes  two-thirds,  of  the  persons  who  own  the  lands 
to  be  drained  and  who  signify  their  desire,  according  to  certain  legal  matters, 
that  such  lands  be  drained.  If  a  petition  be  approved,  then  all  action  from  that 
time  is  according  to  certain  definite  and  carefully  prescribed  legal  procedure  and 
under  the  care  and  supervision  of  local  or  County  and  State  authorities.  Every 
possible  precaution  is  exercised  to  make  it  a  strictly  business  proposition,  free 
from  speculation  and  from  exploitation  for  personal  gain.  Taxes  are  levied 
upon  the  land  to  pay  the  initial  expenses,  and  after  that  drainage  bonds,  as 
they  are  called,  are  issued,  for  the  continuing  costs  and  for  the  completion  of 
the  work.  Taxes  are  levied  annually  to  pay  the  interest  and  principal  on  the 
bonds,  which  are  a  first  lien  on  the  land,  the  same  as  any  State  taxes.     The 

*It  is  hoped  that  in  the  near  future  the  Bureau  of  Entomology  will  publish  a  reasonably  complete  account 
of  this  experiment,  which  would  seem  readily  feasible  of  imitation  in  other  and  even  more  important  localities 
of  the  South  where  rural  economic  progress  is  hindered  by  the  prevalence  of  malarial  disease. 

37 


bonds  bear  from  five  to  six  per  cent,  interest,  and  run  from  twenty  to  forty  years, 
being  generally  on  the  amortization  plan.  They  are  usually  regarded  as  sound 
securities  and  safe  investments.  Both  laws  and  methods  of  procediire  differ 
somewhat  in  details  in  the  various  States,  but  are  essentially  the  same  in  the 
principles  involved  and  the  results  attained. 

Among  the  more  conspicuous  illustrations  of  successful  drainage  eflForts 
in  this  country  attention  is  directed  to  the  Little  River  Drainage  District 
of  southeast  Missouri  and  certain  drainage  districts  of  southern  Louis- 
iana. The  magnitude  of  the  drainage  operations  in  southeastern 
Missouri  is  emphasized  in  the  statement  that  the  Little  River  drainage 
project  alone  embraces  560,000  acres  of  swamplands,  equivalent  to  an 
area  of  1,136  square  miles,  being  about  ninety  miles  long  and  from  four 
to  thirty  miles  in  width.  The  cost  of  construction  will  amount  to  about 
$5,000,000,  and  the  work  is  now  nearing  completion.  It  is  explained 
that  the  cost  of  drainage  in  Missouri  has  varied  from  about  $3  to  $7  per 
acre,  but  that  to  this  must  be  added  the  cost  of  clearing  the  land  when 
timbered,  which  varies  from  $12  to  $50  per  acre.  Cleared  land,  it  is 
said,  ranges  in  price  from  $50  an  acre  upwards.  The  soil  is  generally  of 
unusual  fertility,  "since  most  of  the  land  is  alluvial  deposit  from  some 
neighboring  river.  The  soil  is  usually  very  rich  in  humus,  because  of 
centuries  of  decaying  vegetable  matter.  As  there  is  naturally  an  abun- 
dance of  moisture,  it  possesses  all  the  requisites  of  abounding  yields."* 

In  the  same  bulletin  is  a  brief  statement  regarding  the  remaining 
swamplands  of  the  United  States,  the  area  of  which  is  estimated  as 
79,000,000  acres,  of  which  52,665,000  acres  represent  permanent  swamps, 
6,826,000  acres  wet  grazing  land,  14,757,800  acres  periodically  overflowed 
land,  and  4,766,000  acres  periodically  swampy  land.  These  79,000,- 
000  acres  of  swamplands,  it  is  explained,  are  equal  to  seventy-five  per 
cent,  of  the  entire  corn  acreage,  and  theit  area  is  seventy-five  per  cent, 
greater  than  the  acreage  of  both  winter  wheat  and  spring  wheat  com- 
bined. Aside,  however,  from  the  foregoing,  it  is  estimated  "that  there 
are  150,000,000  acres  of  what  is  known  and  occupied  as  farm  land,  which 
is  too  wet  for  the  most  profitable  cultivation,  and  whose  production 
would  be  increased  twenty  per  cent,  by  proper  drainage,  f 

•Important  descriptive  accounts  of  this  section  are  the  following:  "Missouri's  Swamp  and  Overflowed 
Lands  and  Their  Reclamation,"  by  John  H.  Nolen,  made  to  the  Forty-seventh  Missouri  General  Assembly, 
January,  1913,  Jefferson  City,  Mo.,  also  "The  Little  River  Drainage  District  of  Missouri,"  a  review  of  its 
Securities,  General  Information,  Engineer's  Report  and  Attorneys'  Opinion,  Cape  Girardeau,  Mo.,  1913. 

tA  useful  contribution  to  this  aspect  of  the  malaria  problem  is  Bulletin  No.  32,  on  Agricultural  Drainage  in 
Georgia,  published  by  the  Geological  Survey  of  Georgia,  Atlanta,  1917,  including  important  statistical  data  as 
regards  the  periodically  overflowed  and  permanent  swamplands  and  a  full  account  of  the  drainage  character- 
istics of  Georgia  and  typical  drainage  projects  in  the  Coastal  Plain.  Of  value  also  is  Farmers'  Bulletin  No.  815 
of  the  U.  S.  Department  of  Agriculture,  on  Organization,  Financing,  and  Administration  of  Drainage  Districts, 
by  H.  S.  Vohe,  Expert  on  Drainage  Organization,  Washington,  June,  1917. 


MOSQUITO  EXTERMINATION  IN  NEW  JERSEY 

Foremost  among  the  States  in  which  the  most  encouraging  progress 
has  been  made  in  mosquito  eradication  and  control  is  New  Jersey.  The 
efforts  in  the  main  have  been  directed  towards  the  eradication  of  the 
mosquito  as  a  nuisance  and  a  discomfort,  rather  than  as  a  menace  to 
health,  but  there  can  be  no  question  of  doubt  but  that  the  results  have 
also  had  a  measurable  effect  upon  malaria.  The  disease  has  not  for 
many  years  been  of  serious  frequency  in  the  State  of  New  Jersey,  but 
in  a  mild  form  and  as  a  complicating  factor  it  has  probably  been  more 
common  than  is  generally  assumed.  The  work  in  New  Jersey  rests 
primarily  upon  the  initiative  of  the  late  Dr.  John  B.  Smith,  State 
Entomologist,  and  the  indefatigable  efforts  of  his  successor,  Dr.  Thomas 
J.  Headlee.  The  work  that  is  being  done  is  concisely  set  forth  in  the 
annual  reports  of  the  New  Jersey  Mosquito  Extermination  Association, 
according  to  which  the  average  cost  of  mosquito  freedom  is  less  than 
fifteen  cents  per  capita,  which,  in  the  words  of  the  president  of  the  As- 
sociation, Dr.  William  Edgar  Darnall,  of  Atlantic  City,  "is  not  much 
to  pay  for  the  health  and  wealth,  the  comfort  and  prosperity,  that  will 
follow  its  accomplishment."  Dr.  Darnall,  quoting  from  the  report  of 
Dr.  Headlee,  points  out  in  this  connection  that 

Approximately  95,000  acres  of  the  salt  marsh  have  been  rendered  reasonably 
free  from  mosquito  breeding.  This  has  involved  the  cutting  of  11,500,000  feet 
of  ditches  ten  inches  wide  and  thirty  inches  deep,  or  their  equivalent,  the  build- 
ing of  17.2  miles  of  dike,  the  installation  of  seventy-six  sluice  and  tide-gates 
(representing  842  square  feet  of  cross-section  outlet  opening),  the  installation  of 
one  four  and  one  twelve-inch  centrifugal  pump  and  the  connection  of  100  acres 
of  marsh  with  a  large  sewage-pumping  plant.  Approximately  fifty  per  cent. 
of  the  reasonably  permanent  fresh-water  mosquito-breeding  pools,  scattered 
over  315,000  acres  of  upland,  has  been  permanently  eliminated. 

Facts  of  this  character  constitute  the  most  encouraging  evidence 
of  a  clear  realization  of  the  social  and  economic  importance  of  mosquito 
eradication.*  What  holds  true  for  New  Jersey  in  a  general  way  holds 
equally  true  for  more  southern  communities  in  which  the  problem  of 
mosquito  eradication  involves  the  larger  question  of  malaria  control. 
In  New  Jersey  the  anopheles  mosquito  is  relatively  rare,  but  sufficiently 
common  to  constitute  a  menace  to  the  health  of  a  large  number  of  im- 
portant communities  in  the  event  of  the  reintroduction  of  malarial 
disease  through  returning  soldiers  and  others  from  infected  commu- 
nities, camps,  cantonments,  etc.,  in  the  South.     What  has  been  done  is 

*0f  value  in  the  consideration  of  local  eradication  efforts  in  this  country  is  the  North  Shore  Improvement 
Association:  Report  on  Plans  for  the  Extermination  of  Mosquitoes  of  the  North  Shore  of  Long  Island,  1902. 

39 


best  illustrated  by  a  statement  made  by  the  president  of  the  New 
Jersey  Mosquito  Extermination  Association,  reading  that:  "One  and 
three-quarter  millions  of  people  of  New  Jersey  have  been  given  a 
very  considerable  measure  of  protection  against  the  mosquito  and  at  a 
cost  of  only  $210,000  (per  annum),  or  a  per-capita  cost  of  about  twelve 
cents." 

MOSQUITO  EXTERMINATION  IN  ESSEX  COUNTY 

Of  especial  importance  is  the  work  which  has  been  done  in  Essex 
County,  including  the  city  of  Newark.  The  law  creating  a  County 
Mosquito  Extermination  Commission  became  operative  in  1912.  The 
extermination  ratables  on  the  Newark  meadows,  comprising  land  im- 
provement and  personal  property,  amounted  to  $1,428,000.  The 
values  have  increased  every  year,  reaching  $3,750,000  by  1916.  The 
tax  income  from  these  ratables  increased  from  $19,656  in  1912  to  $64,- 
155  in  1916,  The  number  of  persons  employed  in  the  industries,  etc., 
located  in  the  meadow  area*  in  1912  was  only  286,  earning  $152,000  per 
annum;  in  1916  the  number  employed  was  6,341,  with  a  yearly  pay-roll 
of  $2,863,000.  As  observed  by  Dr.  Frederick  W.  Becker,  member  of 
the  Essex  County  Mosquito  Extermination  Commission,  "Without 
mosquito  extermination  this  wonderful  industrial  development  would 
have  been  impossible,  and  it  demonstrates  clearly  that  mosquito  elimina- 
tion is  a  paying  proposition."  In  addition  to  this,  attention  may  be 
directed  to  the  fact  that  the  new  Port  of  Newark,  including  perhaps  the 
largest  ship -building  plant  in  the  country,  and  essential  military  estab- 
lishments connected  therewith,  is  located  in  this  area,  than  which 
there  is  perhaps  at  the  present  time  not  a  much  more  important  one  in 
its  relation  to  the  winning  of  the  war,  to  the  extent  that  the  health  of  the 
army  of  men  ultimately  to  be  employed  there  is  conserved,  and  that 
their  comfort  while  at  work  is  increased  by  the  extermination  or  con- 
siderable reduction  of  the  mosquito  nuisance.  The  results  secured  will 
be  out  of  all  proportion  to  the  expense  incurred. 

The  practical  value  of  mosquito  extermination  in  New  Jersey  as  an  aid 
in  malaria  eradication  is  further  emphasized  by  the  statement  that, 
against  an  average  mortality  from  malaria  of  27.3  per  100,000  during 
1880-1884  and  a  rate  as  high  as  3.7  per  100,000  during  1900-1904,  the 
rate  has  been  reduced  to  1.7  during  1905-1909,  to  0.8  during  1910-1914, 

•A  comprehensive  report  on  the  Drainage  of  the  Hackensack  and  Newark  Tide  Marshes,  by  C.  C.  Vermeule, 
was  included,  as  Part  VI,  in  the  Annual  Report  of  the  State  Geologist  of  New  Jersey  for  the  year  1896.  This 
was  followed  by  an  additional  report  published  as  Part  V  of  the  Annual  Report  for  1897.  Much  useful  infor- 
mation, including  maps  in  considerable  detail,  is  contained  in  the  annual  report  of  the  New  Jersey  Harbor 
Commission,  Mr.  J.  Spencer  Smith,  President,  for  1915. 

40 


to  0.5  during  1915  and,  finally,  to  0.3  during  191G.  With  the  single 
exception  of  the  year  1914,  when  the  rate  was  the  same,  the  rate  for  1916 
was  the  lowest  on  record  since  1880!  By  contrast,  in  the  State  of  Con- 
necticut, where  mosquito-eradication  efforts  have  been  less  effective,  the 
death  rate  during  1915  was  1.4  per  100,000,  against  0.5  for  New  Jersey. 

For  Essex  County  the  expenditures  on  account  of  mosquito  extermina- 
tion amounted  to  $53,608.78  during  the  fiscal  year  1916-1917.  During 
1915  the  Essex  County  Mosquito  Extermination  Commission  employed 
seventeen  inspectors,  thirty-five  assistant  inspectors  and  thirty-nine 
laborers,  who  ascertained  69,010  mosquito -breeding  places,  115,956 
places  liable  to  become  such,  aside  from  making  over  600,000  yard  in- 
spections. The  report  of  the  Commission  for  that  year  includes  a  chart 
showing  the  daily  rainfall,  the  temperature  and  the  wind  movement. 
A  map  is  also  included  showing  the  direction  of  flight  and  the  sources 
of  salt  marsh  mosquitoes  and  the  comparative  density  of  adult  mos- 
quitoes of  all  species.  Supplementary  data  of  the  Commission  show  the 
correlation  of  rainfall  and  temperature  to  the  number  of  adult  mos- 
quitoes caught  per  station  throughout  Essex  County  between  June  6, 
1917,  and  September  17,  1917,  The  several  species  are  properly 
differentiated,  and  in  amplification  of  the  general  chart  there  are  curves 
showing  the  percentage  composition  of  adult  mosquitoes  in  collections 
from  June  1,  1917,  to  September  12,  1917,  and  of  the  larvae  collections 
during  the  period  from  July  25,  1917,  to  September  12,  1917.  In  final 
form,  a  chart  exhibits  the  concentration  of  C.  Pipiens  in  the  four  topo- 
graphic divisions  of  Essex  County  during  the  period  June  11  to  Septem- 
ber 19,  1917,  to  indicate  the  flight  of  the  various  broods  by  weeks 
throughout  the  period  of  record. 

REVIEW  OF  THE  WORK  OF  MOSQUITO  EXTERMINATION 

COMMISSIONS 

The  literature  of  mosquito  extermination  efforts  in  New  Jersey  is  of 
exceptional  interest  and  practical  importance.  The  first  four  annual 
proceedings  of  the  New  Jersey  Mosquito  Extermination  Association 
constitute  a  most  valuable  source  of  practical  information.  Included 
in  the  proceedings  of  the  First  Annual  Meeting  is  an  account  of  the 
Anti-Mosquito  Work  in  New  York  State,  by  Joseph  J.  O'Connell,  M.  D., 
Health  OflBcer  of  the  Port  of  New  York,  who  properly  points  out  that 
the  work  of  mosquito  eradication  was  initiated  by  his  predecessor.  Dr. 
Alvah  H.  Doty,  who  was  one  of  the  first  to  recognize  the  far-reaching 

41 


importance  of  Reed's  discovery  of  the  agency  of  the  mosquito  in  the 
dissemination  of  yellow  fever.  At  the  Second  Annual  Meeting,  follow- 
ing an  address  by  the  President  of  the  Association,  Dr.  Ralph  H.  Hunt, 
on  the  "Anti-Mosquito  Movement,"  a  symposium  of  papers  was 
presented  on  "Important  Mosquito  Control  Problems  That  Have  Been 
Met  and  Their  Solution,"  followed  by  an  address  on  "Mosquitoes  and 
Their  Relation  to  Man,"  by  Dr.  W.  C.  Gorgas,  Surgeon-General  of  the 
United  States  Army,  and  one  on  the  "Economic  Value  of  Mosquito 
Work,"  by  Dr.  Jacob  G.  Lipman,  Director  of  the  New  Jersey  Agri- 
cultural Experiment  Stations.  These  papers  were  followed  by  a  dis- 
cussion of  the  "Anti-Mosquito  Work  of  the  United  States  Department 
of  Agriculture,"  by  Dr.  Leland  O.  Howard,  Chief  Bureau  of  Ento- 
mology, and  one  of  the  "Cost  of  Anti-Mosquito  Work,"  by  Dr.  Thomas 
J.  Headlee,  Entomologist  of  the  New  Jersey  Experiment  Station,  and 
executive  ojQBcer  in  charge  of  the  station's  antimosquito  work,  and  others. 
At  the  Third  Annual  Meeting  attention  was  concentrated  upon  engineer- 
ing questions,  such  as  the  "Place  of  Dikes,  Sluices  and  Tide-Gates  in 
Mosquito  Extermination,"  "The  Cost  of  Salt-marsh  Drainage  for 
Mosquito  Control,"  "The  Value  of  Experimental  Study  to  the  Practical 
Work  of  Mosquito  Control"  and  a  symposium  on  "The  Taxpayers' 
View  of  Mosquito  Control  Work."  At  the  Fourth  Annual  Meeting 
the  proceedings  were  commenced  with  an  address  on  "The  Present 
Status  of  Mosquito  Control  in  New  Jersey,"  by  Wm.  Edgar  Darnall, 
M.  D.,  of  Atlantic  City,  illustrated  by  maps  and  statistical  tables,  fol- 
lowed by  a  very  practical  address  on  the  "Circulation  of  Water  on  the 
Drained  Salt  Marshes,"  by  James  E.  Brooks,  M.  E.,  of  Glen  Ridge,  N.  J., 
and  many  others.  A  most  important  feature  of  these  annual  meetings 
is  the  concise  presentation  of  the  actual  work  which  is  being  done  in  the 
several  counties  of  the  State  and  the  cost  and  economic  results  which 
are  being  achieved.  Among  the  additional  papers  read  at  the  Fourth 
Annual  Meeting,  special  reference  requires  to  be  made  to  an  address  on 
"The  Malaria  Problem  of  the  South,"  by  H.  R.  Carter,  M.  D.,  and 
another  on  "The  Agricultural  Utilization  of  the  Salt  Marsh,"  by  Jacob 
G.  Lipman,  Ph.  D.  Aside  from  these  annual  reports  of  the  New  Jersey 
Mosquito  Extermination  Association,  the  Union  County  Extermina- 
tion Commission  has  published  six  annual  reports,  and  five  similar 
reports  have  been  published  by  the  Atlantic  County  Mosquito  Ex- 
termination Commission.  At  least  one  report  has  been  issued  by  the 
Essex  County  Commission,  and  a  most  interesting  educational  folder 

42 


on  the  mosquito  has  been  pubhshed  by  the  State  Department  of  Con- 
servation and  Development.  A  somewhat  similar  bulletin  has  been 
made  available  for  educational  purposes  by  the  Nassau  County  Mos- 
quito Extermination  Commission,  Freeport,  New  York.  This  organiza- 
tion is  making  a  determined  effort  to  secure  weekly  reports  on  malaria 
from  all  the  physicians  in  Nassau  County.* 

MALARIA  ERADICATION  IN  NEW  YORK  CITY 

In  New  York  City  malaria  eradication  and  mosquito  extermination 
problems  have  continued  to  receive  qualified  consideration  under  the 
direction  of  Dr.  Haven  Emerson,  the  Health  OflBcer  of  Greater  New 
York.  In  a  report  of  the  Health  Department  for  1913,  as  an  indica- 
tion of  the  earlier  recognition  of  the  importance  of  active  malaria- 
control  measures,  it  is  stated  that 

There  were  thirteen  deaths  from  malaria  during  1913  as  compared  with  ninety 
in  1903.  Deaths  from  this  cause  have  steadily  declined,  and  this  diminution 
has  been  both  real  and  apparent;  real  as  a  result  of  the  anti-mosquito  work,  and 
apparent  because  of  the  laboratory  facilities  for  accurate  diagnosis  offered  the 
medical  profession  by  the  Department  of  Health,  which  eUminated  other  fevers 
that  heretofore  had  been  classified  as  malarial. 

During  the  fifteen  years  1902-1916,  the  number  of  deaths  from 
malaria  oflScially  recorded  in  the  City  of  New  York  was  705.  The 
practical  results  of  eradication  measures  are  best  indicated  by  the  state- 
ment that  during  the  year  1902  there  were  125  recorded  deaths  from 
malaria,  against  only  10  deaths  from  this  disease  during  1916.  Con- 
sidered by  quinquennial  periods  there  were  423  deaths  from  malaria 
during  the  first  five  years,  208  during  the  second  and  only  74 
during  the  third. 

What  has  been  dpne  by  the  Health  Department  of  New  York  City 
since  1913  is  illustrated  by  a  series  of  diagrams  in  a  report  on  "Service 
Cost  and  Results  of  the  Work  of  the  Department  of  Health,"  made  to 
ex-Mayor  John  P.  Mitchell  under  date  of  December  31,  1917,  in  which 
it  is  said  that  in  completing  the  constructive  engineering  program  for  the 

*A  thoroughly  practical  discussion  of  the  mosquito  question  with  reference  to  Migration  as  a  Factor  in 
Control,  by  Thomas  J.  Headlee,  Ph.  D.,  Entomologist  of  the  New  Jersey  Agricultural  Experiment  Stations  and 
State  Entomologist,  read  before  the  American  Association  of  Economic  Entomologists,  has  been  reprinted  in 
the  Scientific  American  Supplement,  No.  2205,  under  date  of  April  6,  1918. 

Some  exceedingly  interesting  work  in  connection  with  mosquito  eradication  by  means  of  salt-marsh  drainage 
has  been  done  in  Nassau  County.  An  exceptionally  valuable  report  regarding  local  operations  was  issued  by 
the  Rockaway  Peninsula  Mosquito  Extermination  Association,  under  date  of  April  1,  1918.  The  work  of  this 
association,  as  far  as  known,  is  the  largest  exclusively  private  mosquito  drainage  project  undertaken  in  this 
country.  The  area  covered  is  given  as  2,965  acres  and  the  number  of  feet  ditched  as  1,292,267,  averaging  435 
feet  per  acre,  at  a  cost  of  $7.61  per  acre. 

43 


elimination  of  the  mosquito,  all  the  large  areas  of  salt  and  fresh  water 
marsh  in  the  city  limits  have  either  been  drained  or  filled,  or  the  work  is 
contracted  for  and  being  rapidly  brought  to  completion.  The  new 
acreage  of  marsh  (fresh  or  salt)  drained  to  prevent  mosquito  breeding, 
under  contract  and  by  the  Department  of  Health  force,  was  30,764 
acres  during  the  five-year  period  1913-1917;  the  linear  feet  of  new 
drainage  ditches  dug  to  prevent  mosquito  breeding  during  the  same 
period  amounted  to  9,952,514  feet,  a  maximum  of  4,309,994  feet  having 
been  reached  in  1916.  Malaria  prevails  in  Greater  New  York  with  a 
widely  varying  degree  of  intensity  in  the  different  boroughs.  During 
the  five-year  period  ending  with  1916  the  highest  rate  of  prevalence  as 
measured  by  the  mortality  returns  occurred  in  the  Borough  of  Rich- 
mond, or  6.3  per  1,000,000  of  population,  followed  by  the  Boroughs  of 
Brooklyn  and  Queens,  with  rates  of  4.0  each,  the  Borough  of  Man- 
hattan, with  a  rate  of  1.9,  and  the  Borough  of  Bronx,  with  a  rate  of  1.1. 
For  Greater  New  York  as  a  whole  the  average  malaria-mortality  rate 
for  the  period  under  review  was  2.7  per  1,000,000  of  population.  The 
actual  number  of  deaths  from  malaria  during  this  period  was  seventy- 
four,  of  which  three  occurred  in  the  Borough  of  Bronx,  three  in  the 
Borough  of  Richmond,  seven  in  the  Borough  of  Queens,  twenty-four 
in  the  Borough  of  Manhattan  and  thirty-seven  in  the  Borough  of 
Brooklyn.* 

Of  especial  historical  interest  in  this  connection  is  a  summary  account 
of  the  work  of  the  Department  of  Health  of  the  City  of  New  York,  as 
carried  on  jointly  by  the  Sanitary  Bureau  and  the  Bureau  of  Preventable 
Diseases,  dated  August,  1915.     The  report  states,  in  part,  that 

"The  successful  anti-mosquito  work  of  the  Department  of  Health  in  certain 
parts  of  the  city  clearly  indicates  that  the  mosquito  may  be  practically  ex- 
terminated throughout  Greater  New  York  within  the  next  five  years,  provided 
the  work  now  being  carried  on  be  continued."  Attention  is  drawn  to  Section 
272  of  the  Sanitary  Code,  which  makes  it  "the  duty  of  those  owning  or  having 
the  management  or  control  of  any  marsh  land  or  other  places  where  mosquitoes 
are  bred  and  developed,  to  fill  in  or  drain  the  same,  or  employ  such  other 
methods  as  will  at  all  times  prevent  the  breeding  of  mosquitoes  in  such  places." 
This  section,  it  is  said,  is  reinforced  by  a  provision  of  the  Charter  (Section  1197), 
which  gives  the  Department  of  Health  the  right  to  do  the  necessary  work  and 
place  a  lien  upon  the  property.     Under  Section  272  of  the  Sanitary  Code,  a 

*Malaria  is  unfortunately  not  a  reportable  disease  in  Greater  New  York.  It  cannot  be  questioned  that  if 
the  disease  were  made  reportable  much  useful  information  would  be  secured  of  value  to  the  health  authorities 
m  the  furtherance  of  local  control  measures  and  general  eradication  efforts.  Malaria  was  made  a  reportable 
disease  in  Massachusetts  in  September,  1914.  During  1915  the  number  of  cases  was  112,  with  6  deaths,  or  a 
fatality  rate  of  5.4  per  cent.  During  1916  only  97  cases  were  reported,  with  4  deaths,  or  a  fatality  rate  of  4.1 
per  cent.  Since  the  fatality  rate  for  Mis'>issippi  is  less  than  one  per  cent,  (see  page  18),  it  is  a  fair  assumption 
that  there  were  probably  ten  times  as  many  cases  in  Massachusetts  as  were  oflacially  reported. 

44 


considerable  amount  of  draining,  oiling,  and  pumping  of  ponds  and  marsh  lands 
has  been  done,  at  the  owners'  expense,  even  singly  or  in  groups,  "in  those  sec- 
tions where  the  value  of  the  property  justifies  the  procedure."  This  plan  or 
method  has  been  fully  sustained  or  supported  by  the  courts.  It  is  pointed  out 
that,  "In  this  way,  all  the  marsh  lands  at  Bayside,  Douglaston,  and  Little  Neck 
have  been  drained  on  order  of  the  Department  of  Health.  In  Flushing  prac- 
tically all  the  marsh  land  from  Jackson  Avenue  to  the  head  of  the  Vleigh  has 
been  drained.  In  the  Bronx,  all  the  marshes  from  the  Hutchinson  River  to  the 
Bronx  River  have  been  drained  with  the  exception  of  about  350  acres,  of  which 
owners  have  not  yet  been  found.  The  entire  marsh  area  of  Pelham  Baj^  has  been 
drained  under  contract  by  the  Park  Department,  the  work  being  carried  on 
under  the  supervision  of  the  Health  Department's  sanitary  engineer.  This 
improvement  is  being  maintained  under  a  separate  maintenance  contract. 
Thus  far,  practically  no  work  has  been  done  in  Brooklyn.  It  is  planned  to 
drain  the  marsh  lands  in  this  Borough  and  all  those  remaining  in  the  Borough 
of  Queens,  under  the  provision  of  the  State  law  described  above.  It  has  been 
unnecessary  to  make  use  of  the  powers  conferred  by  Section  1197,  whereby  the 
work  could  be  done  by  the  Department  of  Health  and  a  Uen  placed  on  the 
property  for  the  expenditure.  Under  the  new  law,  which  applies  only  to 
Brooklyn  and  Queens,  the  Department  has  prepared  plans  of  areas  to  be  drained, 
and  has  outlined  areas  which  wiU  be  benefited  and  on  which  assessments  may 
be  placed." 

Since  October,  1905,  and  up  to  the  date  of  the  report,  23,560  acres  of  salt 
marsh  area  had  been  drained,  by  means  of  8,584,084  lineal  feet  of  ditches.  In 
addition  thereto,  247  acres  of  inland  swamp  area  had  been  drained;  at  an  aggre- 
gate cost  for  both  areas  of  $123,957  to  the  city,  and  $182,470  to  the  owners. 
In  1915,  however,  there  remained  within  the  limits  of  the  Greater  City  9,000 
acres  of  undrained  salt  marshes,  and  1,000  acres  of  undrained  inland  swamp. 
It  was  estimated  that  the  cost  of  draining  the  salt  marsh  area  would  be  approxi- 
mately $15  per  acre,  but  for  the  inland  swamp  area  the  cost  was  estimated  at 
$100  per  acre.  The  expense  of  completing  the  drainage  work  in  Greater  New 
York  was  estimated  at  $250,000,  but  it  is  pointed  out  that  "By  the  elimination 
of  the  mosquito  nuisance  large  areas  had  been  made  available  for  settlement, 
relieving  the  congested  centers  of  the  city."  Attention  is  also  directed  to  the 
fact  that,  "The  rapid  growth  of  the  Boroughs  other  than  Manhattan  is  well 
known  and  they  are  continuing  to  increase  in  population.  While  transportation 
will  make  them  accessible,  it  is  the  comparative  freedom  from  mosquitoes  in  the 
drained  area  which  is  making  them  habitable.  There  is  no  doubt  that  many  out- 
l3ring  sections  would  show  increased  growth  were  it  not  for  the  mosquito  nuisance. 
It  is  clearly  the  duty  of  the  City  to  do  its  part  toward  making  these  outlying 
sections  more  desirable  for  residents. 

These  rather  extended  observations  on  malaria  eradication  and 
mosquito  extermination  work  in  Greater  New  York  are  of  special  inter- 
est as  illustrating  that  the  practical  urgency  of  such  efforts  is  not 
limited,  as  is  frequently  asserted  or  assumed,  to  the  Southern  States. 
In  fact,  there  are  reasons  for  believing  that  the  diagnosis  of  malaria  is 

45 


often  not  made  in  Greater  New  York,  where  the  disease  is  merely  a  com- 
pHcating  factor  and  not  of  predominant  importance. 

PROBLEMS  OF  CLINICAL  DIAGNOSIS 

Since  malaria  is  not  a  reportable  disease  in  Greater  New  York, 
morbidity  returns  are  unfortunately  not  available.  Since  the  question 
of  accuracy  and  completeness  in  both  malaria  morbidity  and  mortality 
statistics  is  raised  with  sufficient  frequency  to  require  some  con- 
sideration, the  following  observations  derived  from  the  "System  of 
Clinical  Medicine,"  by  Savill,  are  included  for  the  purpose  of  convenient 
accessibility : 

Malaria  is  rarely  mistaken  for  other  diseases ;  but  the  other  disorders  attended 
by  intermitting  pyrexia  about  to  be  described  are  very  frequently  mistaken  for 
malaria.  Clinically,  this  mistake  would  be  avoided  if  it  were  remembered  that 
malaria  of  true  quotidian  periodicity — daily  recurrence — is  very  rare;  and  that 
tertian  or  quartan  periodicity  is  absolutely  pathogonomonic ;  it  occurs  in  no 
other  disease.  Therapeutically,  the  diagnosis  may  be  established  by  full  doses 
of  quinine;  if  this  be  given  intramuscularly,  and  fail  to  relieve,  the  attacks  are 
certainly  not  malarial.  The  microscopic  recognition  of  the  parasite  in  the  blood 
requires  considerable  experience,  but  it  is  always  possible  to  find  it  in  blood- 
films,  provided  the  patient  has  not  taken  quinine  for  several  days;  this  is  an 
essential  part  of  the  examination,  and  is,  of  course,  positive  evidence.* 

Savill  also  observes  that  death  usually  occurs  from  complications, 
without  which  malaria  is  not  a  very  fatal  disease,  and  he  seems  to  hold 
that  this  conclusion  applies  to  tropical  countries  as  well  as  to  those  of 
the  temperate  zone.  A.  Rendle  Short,  in  his  "Index  of  Prognosis  and 
End-Results  of  Treatment,"  remarks  in  this  connection  that  it  requires 
to  be  kept  in  mind  that  "A  certain  increase  should  perhaps  be  made  in 
the  death  rate  owing  to  the  fact  that  malaria  predisposes  to  intercurrent 
diseases  such  as  dysentery  and  tuberculosis,  and  in  persons  with  a  fatty 
or  a  poisoned  heart,  as  in  beri-beri,  it  may  by  direct  toxic  effect  cause  a 
fatal  termination  of  these  diseases.  Where  the  vessels  are  atheroma- 
tous, cerebral  hemorrhage  may  occur  as  a  result  of  the  high  blood- 
pressure  common  in  some  cases  of  malaria.  Premature  labor  and  abor- 
tion are  not  uncommon,  either  as  a  result  of  the  disease  or  of  injudicious 
treatment  with  quinine.  Still-births  and  high  infantile  mortality  are 
not  infrequent  in  parturient  women  with  malaria." 

Considerable  practical  significance  requires  to  be  attached  to  these 
observations  in  the  correct  interpretation  of   malaria-mortality  returns 

*This  statement  cannot  be  accepted,  in  view  of  the  well-known  fact  that  the  microscopical  diagnosis  of 
obviously  frank  cases  of  malaria  is  frequently  impossible. 

46 


for  localities  or  sections  where  the  disease  is  generally  assumed  to  be 
infrequent  or  practically  absent,  at  least  in  a  fatal  form.  That  the 
diagnosis  of  malaria  is  often  extremely  involved  is  clearly  emphasized  in 
even  an  abbreviated  form  of  the  principal  complications,  more  or  less 
after  the  "Index  of  Differential  Diagnosis,"  by  Herbert  French,  as  fol- 
lows: 

Amenorrhea;  amaemia;  arteriosclerosis;  ascites;  bronchitis,  acute  and  chronic; 
bronchopneumonia;  cholecystitis;  cirrhosis  liver;  dysentery,  bacillary;  dys- 
menorrhea; haematemesis;  hypertrophy  liver;  jaundice,  catarrhal,  haemolytic; 
monorrhagia;  metrorrhagia;  nephritis,  acute,  chronic;  orchitis;  paralysis  agitans; 
paraplegia;  perihepatitis;  pneumonia,  lobar;  pregnancy;  scurvy;  splenomegaly 
with  anaemia;  thrombosis,  brain;  tuberculosis;  typhoid  fever;  uncinariasis; 
valvular  disease  heart. 

Of  these  perhaps  the  most  important  are  the  active  congestion  of  the 
liver,  albuminuria,  pneumonia,  hematuria,  jaundice  and  spleen  enlarge- 
ment. Of  recent  years  much  has  also  been  made  of  the  possible  inter- 
relation of  malaria  and  appendicitis.  Dr.  W.  J.  Hunt,  of  Glens  Falls, 
New  York,  in  1904,  reported  an  interesting  series  of  cases  of  malaria 
which  simulated  appendicitis,  emphasizing  the  conclusion  that  certainty 
in  diagnosis  was  not  always  justified  where  a  malarial  infection  was 
known  to  exist.  Dr.  Hunt  made  the  observation  at  the  time  that  there 
was  so  little  malaria  in  the  State  of  New  York  that  the  physicians  of 
the  State  were  far  from  familiar  with  the  symptomatology  of  the  dis- 
ease, so  that  it  was  easier  for  the  disease  to  be  mistaken  and  to  be 
overlooked  by  them  than  by  physicians  living  in  a  malarial  region. 
The  possibility  of  malaria  simulating  appendicitis  had  made  him  exceed- 
ingly cautious  in  making  a  diagnosis  of  appendicitis  in  one  coming  from 
a  malarial  region.  Graham  E,  Henson,  in  his  work  on  malaria,  refers  to 
the  differentiation  of  appendicitis  from  this  disease,  with  special  refer- 
ence to  a  case  originally  reported  as  one  of  benign  tertain  malaria 
with  very  marked  symptoms  of  appendicitis,  as  follows : 

An  initial  chill,  followed  by  a  temperature  of  99.2  degrees  Fahrenheit,  with 
intense  pain  over  the  region  of  the  appendix,  vomiting,  and  a  marked  rigidity  of 
the  right  rectus,  caused  a  tentative  diagnosis  of  appendicular  colic.  The  follow- 
ing day  the  condition  had  very  much  improved,  and  the  patient  was  compara- 
tively comfortable,  but  forty-eight  hours  from  the  initial  symptoms,  a  chill,  with 
all  the  previous  accompanying  symptoms  intensified,  and  temperature  of  106  F., 
which  fell  in  a  few  hoiu-s  to  nearly  normal,  caused  him  to  suspect  malaria,  at 
least  as  a  complication.  An  examination  of  the  blood  revealed  the  tertian 
Plasmodia  in  large  numbers ;  antimalarial  treatment  was  followed  by  a  complete 
cessation  of  all  abdominal  symptoms,  and  the  patient  went  on  to  a  rapid  re- 
covery. 

47 


"Appendicitis,"  according  to  Henson,  "can  be  differentiated  from 
malaria,  by  the  absence  of  plasmodia  in  the  blood,  and  a  marked  leuco- 
cytosis,  with  great  excess  of  polynuclears.  Too  much  attention  should 
not  be  paid  to  pain  in  the  abdomen,  as  it  is  often  a  prominent  symptom 
in  malaria,  as  well  as  appendicitis."  Henson  also  reported  a  case  of 
tertian  malaria  simulating  appendicitis  in  1911,  suggestive  of  at  least 
the  occasional  occurrence  of  serious  mistakes  in  diagnosis,  and  emphasiz- 
ing the  urgency  "on  all  practitioners  in  malarious  districts  of  the  neces- 
sity for  the  examination  of  the  blood  for  the  malaria  parasite,  and  the 
value  of  the  procedure  as  a  routine  measure."  The  Florida  case  re- 
ferred to  by  Henson  is  of  special  interest  in  connection  with  the  reported 
frequency  of  appendicitis  in  certain  counties  of  southern  Georgia, 
all  of  which  are  known  to  be  more  or  less  malarious. 

Since  there  are  no  references  to  malaria  as  a  complicating  factor  in 
appendicitis  or  as  a  cause  of  mistaken  diagnosis  in  the  standard  treatise 
on  "Appendicitis,"  by  Howard  Kelly,  nor  in  the  discussion  of  the  more 
prominent  symptoms  and  complications  in  "The  Malarial  Fevers  of 
Baltimore,"  by  Thayer  and  Hewetson,  it  would  seem  appropriate  to 
suggest  that  this  rather  neglected  aspect  of  the  disease  may  be  deserving 
of  more  extended  and  qualified  consideration.* 

MALARIA  ERADICATION  IN  CALIFORNIA 

The  foregoing  observations  regarding  the  differential  diagnosis  of 
malaria  apply  with  special  emphasis  not  only  to  New  York,  New  Jersey 
and  the  New  England  States,  but  also  to  California.  The  vast  area  of 
the  Northern  or  Sacramento  Valley  and  the  Southern  or  San  Joaquin 
Valley  has  ever  since  the  discovery  of  gold  and  the  enormous  influx  of 
population  from  all  parts  of  the  globe  been  more  or  less  seriously  in- 
fected with  malarial  disease.  In  recognition  of  the  practical  importance 
of  a  better  public  appreciation  of  the  malaria  problem,  a  series  of  papers 
on  the  subject  was  presented  before  the  Commonwealth  Club  of  Cali- 
fornia, at  its  March  meeting,  1916.  The  discussion  included  the  report 
of  a  special  committee  on  malaria  in  California,  presented  by  Dr.  George 
E.  Ebright,  President  of  the  State  Board  of  Health,  a  report  on  the 
administrative  work  in  the  prevention  of  malaria,  by  Ray  Lyman 
Wilbur,  President  of  Stanford  University,  a  discussion  of  methods  of 

*Dr.  E.  A.  Codman  in  his  Study  on  Hospital  Efficiency  as  Demonstrated  by  the  Case  Reports  of  the  First 
Five  Years  of  a  Private  Hospital  (Boston,  1918)  included  case  No.  18  of  a  female,  age  38,  admitted  on  account 
of  intermittent  right-sided  abdominal  pain  and  one  attack  of  jaundice  of  which  the  preoperative  diagnosis  was 
for  gallstones.  The  operation  disclosed  no  gallstones,  but  the  appendix  was  removed.  The  complications 
included  an  attack  of  malaria  in  the  second  week,  the  presence  of  the  parasite  having  been  demonstrated  by 
Dr.  G.  E.  Shattuck. 

48 


malaria  control,  by  William  B,  Herms,  associate  professor  of  para- 
sitology in  the  University  of  California,  and  a  presentation  of  the  sources 
of  malaria  in  California,  by  Dr.  Karl  F.  Meyer,  associate  professor  of 
tropical  medicine  in  the  University  of  California.  In  the  report  of  the 
committee,  attention  is  drawn  to  the  fact  that  before  1850  malaria  was 
unknown  in  California,  and  that  the  disease  was  brought  to  the  Pacific 
Coast  by  emigrants  from  the  Mississippi  Valley,  the  Isthmus  of  Panama 
and  Italy.  The  disease  gained  a  permanent  foothold  in  nine  counties: 
Placer,  Shasta,  Sacramento,  San  Joaquin,  Butte,  Tehama,  Fresno, 
Tulare  and  Kern.  In  these  nine  counties  occur  about  seventy -five  per 
cent,  of  the  total  deaths  from  malaria  in  the  State.  The  economic 
cost  of  the  disease  is  estimated  by  the  State  Board  of  Health  at  nearly 
$3,000,000.     The  recommendations  of  the  committee  are: 

1  That  mosquito  control  districts  be  formed  which  shall  cover  all  malaria  in- 
fected areas  in  California  and  that  this  be  done  as  rapidly  as  possible. 

2  That  if  by  the  end  of  the  year  1916  this  plan  be  found  ineffectual  or  un- 
satisfactory, the  legislature  should  appropriate  funds  to  be  used  by  the  State 
Board  of  Health  to  employ  a  sufficient  number  of  inspectors  to  undertake  the 
field  work  of  malaria  extermination  under  the  present  authority  of  the  State 
Board  of  Health, 

The  observations  of  Prof.  Herms  are  summarized  as  follows: 

Malaria  control  practically  synonymous  with  mosquito  control.  Need  for 
siu"vey  to  determine  kinds  of  mosquitoes  and  their  distribution.  Anopheles 
quadrimaculatus  the  most  dangerous  mosquito.  Two  hundred  thousand  dollars 
needed  from  state  for  campaign  of  eradication.  Local  campaign.  Oil  for  pre- 
ventive. Right  and  wrong  kinds;  28  to  32  degrees  Beaume  correct;  treated 
stove  oil.  Drainage  of  breeding  pools  important.  Waste  of  irrigation  water 
favors  the  mosquito.  Need  for  county  ordinances.  Danger  from  the  quinine 
treatment  by  which  parasite  may  become  resistant  to  the  remedy.  Quinine  can 
be  made  effective  where  mosqmto  control  impracticable.  Mosquito  does  not 
acquire  malaria  in  swamps,  but  only  from  afflicted  human  beings.  Changes 
undergone  by  parasite  in  human  and  insect  host.  Malaria  propagated  only 
when  conditions  are  favorable  to  it. 

According  to  Dr.  Meyer,  the  method  used  in  the  survey  of  malarial 
conditions  in  California  was  Hmited  to  the  examination  of  school-chil- 
dren. The  results  for  Chico  and  Gridley  are  reported  upon  in  detail. 
The  need  for  educating  the  public  and  for  extending  the  survey  are 
recognized.  Different  methods  of  treatment  are  advised  for  cities  and 
rural  malarial  districts.  It  is  held  that  the  infection  of  city-dwellers 
usually  takes  place  in  country  districts.  The  reduction  in  frequency  by 
quinine  treatment  is  considered  feasible.     The  chief  obstacle  to  the 

49 


campaign  against  malaria  is  indifference  or  apathy  on  the  part  of  the 
medical  profession.     The  jSnal  recommendations  are  as  follows: 

(1 )  An  educational  campaign  in  the  rural  communities  and  among  the  medical 
profession. 

(2)  Instruction  regarding  the  reduction  of  mosquito  bites  by  advocating  per- 
sonal prophylaxis  (mosquito  curtains,  screening  of  house,  etc.).   - 

(3)  Proper  treatment  and  care  of  carriers. 

(4)  Systematic  quinine  treatment  in  badly  infected  ranches  and  rural  districts. 

(5)  A  campaign  has  to  be  based  on  a  careful,  systematic  and  scientific  survey 
of  all  the  conditions  in  the  endemic  region,  before  a  campaign  of  eradication 
promises  the  best  success. 

The  mortality  from  malaria  in  California  during  the  last  five  years  for 
which  the  returns  are  conveniently  available  is  presented  in  the  table 
below: 

MORTALITY  FROM  MALARIA  IN  CALIFORNIA 
1912-1916 

Year  Population  Deaths  jqq  qoo  Pod. 

1912 2,577,137  80  3.10 

1913 2,667,516  57  2.14 

1914 2,757,895  52  1.89 

1915 2,848,275  52  1.83 

1916 2,938,654  54  1.84 

Total 13,789,477  295  2.14 

The  results  of  this  analysis  fully  sustain  the  apprehension  of  those 
familiar  with  the  facts  that  malaria  is  of  much  more  serious  importance 
to  the  people  of  the  State  of  California  than  is  generally  assumed  to  be 
the  case.  The  disease  is  fortunately  on  the  decrease,  the  malaria  death 
rate  having  dechned  from  3.10  per  100,000  in  1912  to  1.84  in  1916. 
But  assuming  that  the  fatality  rate  is  only  2  per  1,000,  the  number  of 
cases  of  malaria  in  California  is  probably  not  much  less  than  25,000 
per  annum,* 

Doctors  Kelly  and  Geiger,  of  Berkeley,  California,  direct  attention 
to  the  fact  that,  although  for  many  years  malaria  has  been  known  to  be 
prevalent  in  the  great  central  valleys  of  California  and  the  foothills 

•By  geographical  divisions  the  average  malaria  mortality  of  California  for  1911-1915  per  100,000  of  popula- 
tion has  been  as  follows: 

In  contrast  to  an  average  rate  of  2.6  for  the  State,  the  rate  for  the  San  Joaquin  Valley  was  5.6,  for  the  North 
and  East  Mountain  counties  8.3,  and  for  the  Sacramento  Valley  13.8.  For  selected  counties,  however,  the  rates 
were  as  high  as  32.9  for  Shasta  County,  22.8  for  Yuba  County,  19.7  for  Kings  County,  18.3  for  Calavaras  County, 
16.2  for  Amadore  County,  15.7  for  Butte  County,  15.6  for  Tehama  County  and  15.5  for  Sutter  County. 

50  . 


adjacent  to  them,  no  systematic  attempt  had  been  made  to  study  the 
types  and  endemicity  of  the  disease  prior  to  1915,  when  Drs.  Meyer 
and  Walker,  associate  professors  of  tropical  medicine  in  the  George 
Williams  Hooper  Foundation  for  Medical  Research,  began  an  investiga- 
tion in  order  to  determine  the  endemicity  of  malaria  and  the  types  of 
mosquitoes  involved,  but  the  investigation  was  discontinued  after  only 
a  few  weeks.  Subsequently,  however,  following  a  conference  with  Prof. 
W.  B.  Herms,  the  author  of  a  standard  treatise  on  "Malaria,  Cause  and 
Control,"  and  an  address  on  "Successful  Methods  of  Attack  on  Malaria 
in  California,"  an  inquiry  was  initiated,  with  the  approval  of  the  Cali- 
fornia State  Board  of  Health,  for  the  ascertainment  of  malarial  con- 
ditions throughout  the  State.  On  account  of  other  and  more  urgent 
investigations,  however,  the  plan  was  not  completely  carried  out,  but  in 
a  contribution  to  The  Journal  of  the  American  Medical  Association,  of 
May  5,  1917,  Drs.  Kelly  and  Geiger  presented  a  brief  report  on  the 
"Endemic  Index  of  Malaria  in  the  Northern  Sacramento  Valley,  Cali- 
fornia," limited,  however,  to  two  localities,  Orland,  Glenn  County, 
and  Redding,  Shasta  County,  with  a  population  of  836  and  3,572, 
respectively,  according  to  the  census  of  1910.  The  malarial  index, 
based  exclusively  upon  school-children,  and  in  conformity  with  the 
methods  perfected  by  the  late  von  Ezdorf,  was  ascertained  to  be 
4.7  per  cent.,  which  compares  with  11.4  per  cent,  for  Alabama,  10.1 
per  cent,  for  Arkansas,  7.8  per  cent,  for  North  Carolina,  11.9  per 
cent,  for  South  Carolina,  31.2  per  cent,  for  Mississippi  and  9.3 
per  cent,  for  Virginia.  It  is  explained,  however,  that  the  relatively 
low  figure  for  California  may  in  part  have  been  the  result  of  dissimi- 
larities in  methods  of  determining  the  index,  for  it  is  said  that  "Speci- 
mens were  taken  from  school-children  only  and  thin  smears  were  used 
exclusively,  while  von  Ezdorf  took  specimens  from  the  general  popula- 
tion and  used  thick  as  well  as  thin  smears.  Taylor  found  only  one- 
fourth  as  many  positive  specimens  using  thin  as  he  did  using  thick 
smears,  so  it  is  possible  that  by  using  the  latter  method  our  positive 
findings  might  have  been  increased,  though  at  least  half  an  hour  was 
spent  in  the  examination  of  each  smear  before  reporting  it  negative." 
It  is  stated  further  that  "The  relatively  high  percentage  of  estivo- 
autumnal  infections  is  of  interest,  particularly  in  Redding,  where  the 
number  of  cases  of  this  type  was  the  same  as  the  tertian,"  but  it  is  said 
"this  is  higher  than  the  percentage  reported  by  von  Ezdorf,  who  found 
two  tertian  for  every  estivo-autumnal  infection."     The  percentage  of 

51 


carriers  was  ascertained  to  be  the  highest  between  ages  11  and  15.  The 
results  of  the  investigation  are  numerically  too  limited  to  be  entirely 
conclusive,  but  the  investigation  is  a  most  promising  indication  of 
progress  in  the  right  direction.* 

ECONOMIC  ASPECTS  OF  EXTERMINATION  MEASURES 

It  is  upon  efforts  like  these  that  the  ultimate  practical  solution  of  the 
malaria-reduction  problem  depends.  It  is,  after  all,  a  question  of  cost 
and  economic  results.  It  is,  therefore,  seemingly  of  the  utmost  im- 
portance that  all  methods  of  eradication,  in  this  country  at  least,  should 
rest  upon  economic  as  well  as  medical  considerations :  for  even  though  it 
might  be  ideally  possible  to  eradicate  or  control  malaria  by  the  most 
rigorous  methods  of  quinine  prophylaxis  or  the  quinine  immunization 
of  the  entire  population,  the  results  would  be  to  small  practical  purpose 
unless  the  expense  incurred  was  proportionate  to  the  social  and  economic 
benefits  resulting  therefrom.  Few  communities,  if  any,  are  likely  to 
incur  heavy  expenditures  in  behalf  of  a  single  method  of  malaria  eradica- 
tion or  control,  if  a  more  comprehensive  policy  is  likely  to  also  serve  a 
number  of  other  important  purposes  and  aid  more  effectively  in  secur- 
ing the  required  results.  Considered  from  this  point  of  view,  it  is  practi- 
cally hopeless  to  separate  the  problem  of  malaria  eradication  from  the 
broader  question  of  mosquito  extermination,  or  from  the  still  more  im- 
portant considerations  of  minor  and  major  drainage  for  agricultural  and 
other  purposes.  The  reclamation  of  the  Newark  Meadows  has  been  of 
enormous  value  to  Essex  County,  the  State  of  New  Jersey  and  the  nation 
at  large.  If  the  prevailing  type  of  mosquito  had  been  the  anopheles,  or 
malaria-carrying  species,  and  if  malaria  had  been  ten  times,  or  even  a 
hundred  times,  more  frequent,  there  would  not  have  been  the  public 
interest  in  the  problem  of  malaria  eradication  or  mosquito  extermination 
if  the  outlook  had  not  been  also  distinctly  encouraging  that  the  resulting 
economic  benefits  would  be  in  proportion  to  the  necessary  expense.  To 
the  extent  that  extermination  or  eradication  efforts  rest  upon  an  eco- 
nomic basis,  the  outlook  for  permanency  in  results  is  decidedly  greater 
than  in  the  case  where  the  underlying  considerations  are  purely  medical, 
as  is  the  case  in  quinine  prophylaxis  or  quinine  immunization,  etc.,  for 

*The  most  recent  report  on  malaria  in  California  is  by  Stanley  B.  Freeborn,  M.  S.,  Acting  Consulting 
Parasitologist,  California  State  Board  of  Health,  Monthly  Bulletin,  April,  1918.  This  report  reviews  the  history 
of  eradication  efforts  since  1903,  and  presents  an  admirable  summary  of  what  has  been  done  since  the  adoption 
of  the  Mosquito  Abatement  Districts  Bill,  chiefly  with  reference  to  San  Rafael,  Marin  County,  Los  Molinos, 
Tehama  County,  and  the  Matadero  Districts  at  Palo  Alto.  This  district,  it  is  pointed  out,  "no  doubt  con- 
tributes enormous  supplies  of  mosquitoes  to  Camp  Fremont."  Nine  mosquito  abatement  districts  have  now 
been  organized  with  promising  results. 

52 


the  latter  leaves  the  larger  problem  of  general  health  and  well-being  prac- 
tically unsolved.  It  directly  benefits,  unquestionably,  the  population 
concerned  in  the  more  or  less  complete  elimination  of  malarial  disease, 
but  it  fails  to  solve — since  it  cannot  solve — problems  of  general  sanita- 
tion, minor  drainage,  the  elimination  of  stagnant  water,  etc.  To  the 
end  that  the  solution  of  a  number  of  sanitary  problems  can  be  concen- 
trated in  a  single  effort  and  made  the  subject  of  a  single  expenditure, 
the  required  public  support  is  much  more  likely  to  be  forthcoming  and 
continue  than  where  the  eradication  effort  concerns  only  a  single  phase 
of  a  large  and  often  extremely  complex  situation.* 

MALARIA  CONTROL  WORK  IN  INDIA 

In  support  of  local  mosquito-extermination  and  malaria-eradication 
measures  thoroughly  scientific  investigations  are  urgently  required,  and, 
in  fact,  absolutely  necessary  if  satisfactory  results  are  to  be  achieved. 
There  has  not  been  in  this  country  the  active  scientific  interest  in  this 
respect  which  has  been  developed  in  tropical  countries,  especially  in 
India,  Ceylon,  the  Federated  Malay  States  and  the  Straits  Settlements.! 
It  is  probably  true,  of  course,  that  malaria  is  not  as  serious  a  menace  to 
health  even  in  the  most  infected,  highly  endemic  areas  of  this  country  as 
in  certain  tropical  regions  of  Asia,  Africa  and  South  America,  but  the 
facts  in  support  of  this  assumption  have  not  as  yet  been  ascertained 
with  the  required  degree  of  thoroughness.  No  strictly  scientific  malaria 
survey,  for  illustration,  has  thus  far  been  made  of  certain  counties  of 
southeastern  Missouri,  which  are  known  to  be  intensely  malarious;  nor 
have  such  investigations  been  made  of  certain  thoroughly  infected 
counties  of  Arkansas,  Mississippi  and  Louisiana,  or  been  reported  upon 
in  conformity  to  the  admirable  descriptive  accounts  which  are  available 
for  many  and  almost  unknown  localities  of  Asia,  northwestern  Argen- 
tine and  the  West  Coast  of  Africa.  Such  work,  for  illustration,  as  has 
been  done  by  the  Special  Malaria  Department  of  the  Corporation  of 

*Quinine  immunization  unquestionably  is  of  real  value  in  localities  or  sections  where  the  inhabitants  are 
chiefly  natives,  where  an  effective  public  health  organization  is  wanting,  where  the  density  of  population  is  lowi 
where  the  climatic  conditions  are  decidedly  unfavorable,  and  where  for  topographic  as  well  as  for  economic 
reasons  mosquito  eradication  and  control  would  be  impossible.  A  typical  section  of  this  kind  would  be  certain 
large  portions  of  the  lower  Amazon  River  country  in  Brazil,  where  efforts  to  successfully  establish  American  rubber 
plantations  have  been  exceedingly  difficult  on  account  of  the  high  mortality  rate  from  malaria.  Equally  difficult 
and  not  far  from  disastrous  was  the  early  experience  in  the  building  of  the  Mamore  Madeira  Railway.  Con- 
clusions favorable  to  quinine  immunization  in  strictly  tropical  and  more  or  less  primitive  regions  are  hardly 
applicable  to  the  malarial  portions  of  such  a  thoroughly  developed  and  highly  civilized  country  as  the  United 
States,  except  as  a  temporary  expedient  in  the  most  infected  portions  of  the  Yazoo  Delta  or  the  swamplands  of 
southeastern  Missouri. 

tAn  extensive  account  of  the  antimalarial  measures  in  the  Straits  Settlements  is  included  in  a  treatise  on 
"Rural  Sanitation  in  the  Tropics,"  by  Malcolm  Watson,  M.  D.,  New  York,  1915. 

53 


Madras  has  not  its  equal  at  the  present  time  in  this  country.*  The 
Madras  report  includes  maps,  illustrations  and  statistics  for  1916. 
The  analysis  of  the  malaria  mortality  is  by  wards  and  months,  and 
according  to  sex.  The  statistics  indicate  a  wide  range  in  local  fre- 
quency, from  a  minimum  rate  of  0.2  per  1,000  for  one  ward  to  a  maximum 
rate  of  4.2  for  another.  The  rates  for  1916  are  in  marked  and  gratifying 
contrast  to  the  excessive  rates  prevailing  in  former  years,  for  during  the 
preceding  quinquennial  period  the  minimum  rate  of  malaria  mortality 
was  1.7  per  1,000,  and  the  maximum  12.5.  The  precise  ascertainment 
of  local  conditions  in  the  different  wards  subject  to  a  high  or  a  low  rate 
of  mortality  from  malaria  is  the  chief  function  of  the  officer  in  charge 
of  the  Madras  Malaria  Department.  The  investigations  which  he  is 
required  to  make  include  mosquito  surveys,  of  mosquito  prevalence  in 
wet  fields  or  overflowed  areas,  the  examination  of  children  with  reference 
to  the  existence  of  enlarged  spleen,  the  taking  of  blood  smears  with 
reference  to  the  ascertainment  of  infected  persons,  which  during  1916 
revealed  an  average  of  5.96  per  cent,  and  a  range  from  a  minimum  of 
1.7  per  cent,  to  a  maximum  of  20.6  per  cent.  The  report  includes  a 
digest  of  the  dispensary  statistics  to  which  special  attention  is  directed, 
in  that  they  are  said  to  "afford  a  fairly  reliable  index  for  any  rise  in 
malarial  fevers  in  the  localities  served  by  these  dispensaries,  since  blood 
smears  are  obtained  from  patients  suffering  from  fever  and  resorting 
to  the  malaria  dispensaries  of  the  Corporation."  The  report  also  out- 
lines the  antimalarial  measures  which  have  been  adopted,  and  of  which 
there  are  seven  principal  divisions,  as  follows:  (1)  the  cleaning  of 
ponds,  tanks  and  ditches,  (2)  petrolizing,  (3)  clearing  rank  vegetation, 
(4)  introduction  of  larvacides  (fish  and  ducks),  (5)  quininization, 
(6)  reclamation  and  (7)  drainage.  These  measures  are  all  described  in 
detail  and  illustrated  by  photographs,  as  a  matter  of  record.     The 

'According  to  a  report  on  the  Vital  Statistics  of  the  Madras  Presidency,  transmitted  by  Consul  Lucien 
Memminger,  under  date  of  November  28,  1917,  for  the  calendar  year  1916,  "in  consequence  of  war  conditions 
it  was  not  possible  to  carry  out  any  special  investigations  in  regard  to  malaria.  Itinerating  dispensaries  were 
on  duty  in|  the  districts  of  Chittoor,  Ganjam,  Godavari,  Kurnool,  and  Vizagapatam,  but  in  the  absence  of 
adequate  supervision  over  the  sub-assistant  surgeons  in  charge  there  is  doubt  as  to  the  value  of  the  results 
attained.  The  experiment  is,  however,  being  continued  and  it  has  been  decided  to  start  three  more  dispen- 
saries under  civil  assistant  surgeons,  who  may  be  expected  to  need  less  supervision,  to  work  in  the  malarial 
tracts  of  the  Nellore,  Cuddapah  and  Bellary  districts.  Considerable  progress  is  being  made  in  the  drainage  of 
water-logged  areas  in  Madras  city;  the  conditions  in  the  tracts  adjoining  the  Buckingham  canal  have  improved 
materially  in  recent  years,  though  much  still  remains  to  be  done  in  the  way  of  removing  breeding  places  for 
mosquitoes,  especially  borrow  pits  along  the  railway  line — and  in  other  places  minor  remedial  measures  have 
been  adopted."  Special  antimalarial  measures  were  generally  undertaken  on  a  moderate  scale  by  the  local 
bodies  concerned — some  from  their  own  funds  and  a  few  others  from  special  grants  obtained  from  the  Government 
— under  the  supervision  of  the  local  sanitary  officers :  "  (a)  quinine  administration  to  all  the  people  in  the  affected 
tracts;  (b)  stocking  of  wells  and  tanks  with  larvicidal  fish;  (c)  trimming  of  edges  of  all  tanks,  etc.,  removal  of 
weeds  and  surface  growth  therefrom;  (d)  prohibition  of  wet  cultivation  in  close  proximity  to  human  habitation 
wherever  possible;  (e)  filling  up  of  useless  wells,  ponds,  etc.;  (f)  petrolizing  of  large  collections  of  water." 

54 


expenditures  on  the  part  of  the  city  of  Madras  on  account  of  special 
malaria  work  during  1916  amounted  to  67,342  rupees,  of  which  22,294 
rupees  was  paid  on  account  of  investigation,  prevention,  treatment, 
etc.,  1,902  rupees  on  account  of  conservancy  work  and  repairs,  10,771 
rupees  on  account  of  engineering  staff;  all  of  these  items  being  grouped 
as  permanent  expenditures  under  the  term  "establishment."  For 
general  and  reclamation  work,  etc.,  10,056  rupees  was  expended;  for 
oiling,  cleaning,  fishermen,  bushcutting,  and  the  purchase  of  liquid  fuel, 
11,328  rupees.  For  minor  expenses,  stationery,  printing,  laboratory 
equipment,  contingencies,  rents,  farms,  etc.,  10,991  rupees.  Converted 
into  the  American  equivalent,  the  total  cost  was  only  $21,846,  which  on 
the  basis  of  the  estimated  population  of  Madras  for  1916  represents  a 
per-capita  expenditure  of  four  cents  for  malaria  prevention  work.* 

MALARIA  CONTROL  WORK  IN  BURMA 

Even  more  interesting  and  scientifically  valuable  special  malaria  work 
is  carried  on  in  a  number  of  localities  in  the  Far  East,  of  which  the  very 
names  are  practically  unknown  in  this  country.  In  1912,  for  illustra- 
tion, a  report  was  published  by  the  Government  of  Burma  on  the  in- 
vestigation of  malaria  at  Kyaukpyu,  illustrated  by  a  number  of  maps 
precisely  locating  infected  areas  and  indicating  the  conditions  predis- 
posing to  an  excessive  prevalence  of  the  disease.  This  interesting  report, 
which  was  made  by  the  special  malaria  officer  of  Burma,  Dr.  N.  P. 
O'Gorman  Lalor,  Major,  I.  M.  S.,  includes  a  well-considered  mathemat- 
ical analysis  of  the  spleen-census  returns  in  conformity  to  the  method 
originally  suggested  by  Ross  on  the  recommendations  of  Karl  Pearson,  f 
The  most  valuable  features  of  the  report,  however,  are  the  maps  of  sub- 
divisions and  local  units  clearly  illustrating  the  topography  and  other 
features,  such,  for  illustration,  as  miming  streams,  overflowed  marshes, 
rice  fields,  areas  under  cultivation,  rank  vegetation,  etc.  Such  maps  are 
absolutely  essential  if  the  work  of  malaria  eradication  is  to  be  placed  on  a 
sound  and  permanent  scientific  foundation.  Only  by  means  of  such 
local  studies  made  by  those  thoroughly  qualified  to  do  so  can  the  many 

•The  foot-note  on  page  54  has  reference  to  the  Presidency  of  Madras  as  a  whole.  For  the  City  of  Madras  the 
most  recent  information  is  contained  in  the  Administration  Report  of  the  Corporation  of  Madras  for  1916-1917, 
which  includes  an  admirable  map  prepared  by  the  Anti-Malaria  Section  of  the  Special  Works  Department 
showing  the  Works  Proposed  and  Carried  out  for  Drainage  of  Tanks  in  Purasawakkam.  The  report  itself  is 
evidence  that  regardless  of  the  war  antimalaria  measures  are  being  carried  forward  in  Southern  India  in  con- 
formity to  well-considered  sanitary  engineering  considerations. 

■f'The  Prevention  of  Malaria,"  by  Ronald  Ross,  London,  1910.  Section  27-32,  inclusive,  on  conditions  re- 
quired for  the  production  of  new  infections  in  a  locality,  laws  which  regulate  the  amount  of  malaria  in  a  locality, 
laws  which  regulate  the  number  of  anophelines  in  a  locality,  explanation  of  various  phenomena,  the  measure. 
ment  of  malaria,  the  mortality  and  cost  of  malaria,  pages  153'253. 

55 


new  aspects  of  the  malaria  problem  be  presented  and  the  new  facts 
brought  to  light  in  connection  with  a  subject  which  is  far  from  having 
been  exhausted  as  regards  its  scientific  possibilities.  Thus,  for  illus- 
tration, the  report  of  Major  Lalor  contains  a  note  on  a  parasitical  fly 
which  infests  anopheles  mosquitoes  of  a  certain  species  at  Kyaukpyu, 
and  which  is  usually  found  adhering  to  the  abdomen  of  the  mosquito, 
with  its  probiscus  deeply  sunk  through  the  chitinous  integument, 
through  which  it  sucks  from  the  abdomen  of  the  mosquito  the  blood 
with  which  the  latter  is  engorged.  The  note  regarding  this  parasite  is 
illustrated  by  colored  reproductions  of  original  drawings  and  constitutes 
a  valuable  addition  to  economic  and  medical  entomology.* 

In  the  report  by  Major  Lalor  a  series  of  tables  of  wind  velocity  and 
wind  steadiness  at  Kyaukpyu  is  included,  with  reference  to  which  it 
is  said  that  "Comparing  these  facts  with  the  extent  to  which  mortality 
from  malaria  prevailed  at  Kyaukpyu  during  the  years  corresponding,  it 
will  be  seen  that  lessened  wind  velocity  and  steadiness  in  June  and  July, 
1908,  was  followed  by  an  unusual  rise  in  the  curve  of  mortality  for 
August'  and  September."  This  rise,  it  is  pointed  out,  "after  due  allow- 
ance for  the  mortality  from  other  exceptional  causes,  must  have  been 
due  to  the  increased  malaria."  For  "If  the  relation  is  one  of  cause  and 
eflFect,  it  can  be  accounted  for  by  the  fact  that  the  absence  of  wind  and 
stillness  of  the  atmosphere  favor  the  increased  breeding  and  dispersion 
in  houses  of  malaria-carrying  anopheles." 

MALARIA  SURVEY  OF  CENTRAL  PROVINCES,  INDIA 

Still  more  elaborate  and  scientifically  instructive  is  the  Report  upon 
Malaria  in  the  Central  Provinces  of  India,  by  Major  W.  H.  Kenrick. 
This  report  includes  a  number  of  exceptionally  suggestive  maps  de- 
lineating the  malarial  areas,  according  to  the  degree  of  infection  as  de- 
termined by  the  spleen  index.  The  intensely  hyperendemic  areas  have 
the  following  features  in  common: 

(a)  They  possess  a  permanent  supply  of  clear  water,  in  the  form  of  springs, 
seepage,  or  streams  flowing  from  the  mountain. 

(b)  They  are  surrounded  by  forest  which  provides  the  densest  shade  and 
shelter  to  breeding  grounds. 

(e)  They  are  inhabited  by  dark-skinned  aborigines,  who,  while  being  immune 
to  the  more  serious  results  of  infection,  as  malaria  carriers  keep  up  the  endemic 
rate. 

•A  descriptive  account  of  the  parasites  found  in  infected  local  anopheles  is  included  in  the  Keport  on  the 
Investigation  of  Malaria  in  the  District  of  Katha  issued  by  the  Government  Printing  Office,  Rangoon,  Burma,' 
September,  1913. 

56 


These  tracts  are  said  to  be  particularly  fatal  to  the  fairer-skinned 
non-aborigine  and  outsider,  which  accounts,  from  the  economic  point 
of  view,  for  the  fact  that  the  colonization  of  these  tracts  has  been  found 
extremely  difficult  and  has  practically  been  left  to  the  aboriginal  tribes. 
In  India,  as  elsewhere,  under  given  conditions,  localities  or  districts  with 
a  comparatively  low  rainfall  may  show  an  excessive  incidence  of  malaria, 
or  more  general  distribution  of  cases,  than  districts  with  a  heavy  rainfall, 
for,  as  observed  by  Major  Kenrick,  "within  certain  limits  the  actual 
quantity  of  rainfall  is  not  an  important  factor  in  the  distribution 
of  endemic  malaria."  Conditions  in  connection  with  which  rainfall  is 
of  importance  and  appears  to  influence  the  prevalence  of  the  disease  are 
the  following: 

(a)  The  rainfall  should  be  sufficient  to  prevent  the  drying  up  of  the  springs, 
small  streams,  seepage  water,  etc.,  found  in,  and  near  to,  the  ranges  of  hills  and 
forests. 

(b)  The  prevailing  winds  during  the  latter  part  of  the  monsoon. 

Of  more  general  importance,  however,  it  is  held  that 

Geological  formation  has  a  bearing  upon  the  distribution  of  endemic  malaria 
only  in  so  far  as  it  determines  the  nature  of  the  soil,  with  respect  to  growth  of 
vegetation,  retention  of  moisture,  etc.  The  principal  formation  of  the  Provinces 
is  that  of  the  basaltic  or  volcanic  rocks  known  as  the  Deccan  trap,  which  occupies 
the  greater  portion  of  the  majority  of  the  districts.  The  region  covered  by  these 
rocks  consists  usually  of  undulating  planes,  divided  from  each  other  by  flat- 
topped  ranges  of  hills,  and  its  distinguishing  features  are  the  prevalence  of  long 
grass  and  the  paucity  of  large  trees,  and  the  circumstance  that  almost  all  bushes 
and  trees  are  deciduous.  It  is  noticeable  that  the  most  highly  endemic  localities 
in  the  Provinces  are  found  in  the  area  bearing  these  distinguishing  f eatiires. 

In  measuring  the  intensity  of  the  endemic  prevalence  of  the  disease, 
the  classification  recommended  by  the  Central  Malaria  Committee  was 
adopted.  This  classification  is  as  follows:  "A  hyperendemic  locality 
is  one  in  which  the  average  spleen-rate  among-  the  children  is  above 
fifty  per  cent.;  a  highly  endemic  area,  one  in  which  this  rate  is  between 
twenty -five  and  fifty  per  cent.;  a  moderately  endemic  area,  one  with 
the  rate  between  ten  and  twenty -five  per  cent.;  and  lastly  a  healthy 
area,  one  in  which  the  rate  is  below  ten  per  cent." 

The  larger  areas  of  the  Central  Provinces  are  fully  described  and 
illustrated  by  an  admirable  series  of  maps.  With  reference  to  the  cotton 
area,  which  includes  the  districts  of  Buldana,  Akola,  Amraoti  and 
Yeotmal  of  Berar,  and  Wardha  and  Nagpur  of  the  Nagpur  Division,  it 
is  of  interest  to  note  the  conclusion  that  "The  most  noticeable  feature 

57 


is  the  almost  complete  absence  of  endemic  malaria  from  the  open  tracts 
cultivated  with  cotton."  Upon  the  basis  of  such  statistics  as  were 
available,  the  conclusion  is  advanced  that  "One  might  almost  indicate 
the  distribution  of  endemic  malaria  by  a  map  showing  the  density  of 
rural  areas:  the  lower  the  average  of  density  the  higher  the  endemic 
rate."  These  observations  may  well  be  applied  to  the  vast  cotton  areas 
of  the  Southern  States,  and  particularly  to  those  of  the  Mississippi  Valley. 
In  proportion  as  these  areas  have  been  thoroughly  cleared  and  drained, 
the  incidence  of  malaria  has  materially  diminished,  without  any  other 
factors  of  eradication  or  control.  For  purposes  of  comparison  it  may  be 
stated  that  the  density  of  the  various  districts  of  the  cotton  tract  of  the 
Central  Provinces  has  a  range  from  a  minimum  of  93  persons  per 
square  mile  to  a  maximum  of  247.  The  corresponding  density  for 
the  Delta  counties  of  the  State  of  Mississippi  is  forty-eight  persons  per 
square  mile  for  the  total  population  and  eight  persons  per  square  mile 
for  the  white  population.* 

RICE  CULTIVATION  AND  MALARIA 

A  valuable  contribution  to  the  study  of  local  conditions  more  or 
less  directly  responsible  for  an  excessive  degree  of  malaria  frequency 
is  a  discussion  of  malaria  and  rice  cultivation,  f  It  is  said  that  the 
characteristic  physiography  of  the  rice  tract  in  the  Central  Provinces 
of  India  "is  that  of  an  extensive  plain,  covered  by  small  embanked  rice 
fields,  comprising  the  basins  of  the  Wainganga  and  Mahanadi  Rivers, 
bounded  on  the  north,  east  and  south  by  hilly  country  with  a  belt  of  hill 
and  jungle  separating  the  valley  of  the  Wainganga  from  the  Chhattis- 
garh  plains.  Low  undulations  of  unculturable  gravel  traverse  the  plain 
in  places>  otherwise  it  is  unbroken  except  for  small  patches  of  scrub 
jungle  and  mango  groves.  On  the  borders  where  the  hilly  country 
merges  into  the  plains,. the  cultivated  area  becomes  irregular  and  broken 
up  by  the  encroaching  forest.  The  soil  is  largely  of  a  yellow  sandy 
nature,  formed  from  metamorphic  or  crystalline  rock." 

The  rivers  of  this  area,  except  during  the  rainy  season,  consist  merely 
of  a  series  of  stagnant  pools,  connected  by  a  streamlet  flowing  along  one 
side  of  a  broad  expanse  of  sand.  Tanks  constructed  for  drinking  purposes 

•The  density  of  population  (including  both  white  and  colored)  of  the  Delta  area  has  increased  from  37 
persons  per  square  mile  in  1900  to  48  in  1910.  The  probable  density  at  the  present  time  (1918)  is  between  55 
and  60  per  square  mile,  on  account  of  the  very  rapid  increase  in  the  population  of  certain  sections,  in  conse- 
quence of  health  improvement,  railway  extensions,  the  high  price  of  cotton,  etc. 

fFor  observations  on  malaria,  with  special  reference  to  the  rice-growing  counties  of  California,  see  page  48, 
ei  seq. 

58 


and  for  the  irrigation  of  rice  are  exceedingly  numerous,  there  being  one 
or  more  in  the  neighborhood  of  every  village,  and  as  many  as  28,500 
tanks  in  one  area  alone.  The  majority  of  these  tanks  contain  water 
weeds  and  grass.  The  climate  is  hot  and  dry.  The  mean  rainfall  is 
fifty-three  inches.  The  method  of  cultivation  is  almost  universally 
"broadcast  sowing,"  transplantation  being  practised  in  a  few  places 
only.  Irrigation  is  merely  additional  to  the  rainfall,  and  is  most 
frequently  resorted  to  where  light,  non-retentive  soil  predominates. 
Practically  in  every  village  there  is  some  irrigation  from  tanks  or  rivers. 

An  examination  of  over  thirty  thousand  children  between  the  ages  of 
two  and  ten  years  throughout  this  rice  country  suggests  that,  from  the 
point  of  view  of  malarial  endemicity,  "the  area  should  be  divided  into  a 
healthy  area  with  a  spleen  rate  under  ten  per  cent.,  an  endemic  area  with 
a  rate  between  ten  and  fifty  per  cent,  and  a  hyper-endemic  area  with  a 
rate  above  fifty  per  cent."  According  to  this  division  the  spleen  rate 
in  the  healthy  area  was  4.3  per  cent.;  in  the  endemic  area,  24.1  per  cent., 
and  in  the  hyperendemic  area,  70.5  per  cent.  The  latter  are  those  in 
which  "jungle  and  hill  are  found  in  excess  and  in  close  proximity  to 
villages.  The  greater  extent  to  which  jungle  and  waste  land,  covered 
with  long  grass  or  scrub  and  in  continuity  with  forest,  replaces  open 
cultivation,  the  more  malarious  an  otherwise  healthy  rice  tract  becomes. 
Thus  the  borders  of  the  cultivated  rice  plains  at  the  foot  of  the  moun- 
tain ranges,  the  narrow  valleys  through  which  the  mountain  streams 
debouch  upon  the  plains,  the  small  isolated  patches  of  cultivation  in 
forest  clearings  and  the  fringe  of  the  plateaux,  when  bordered  by  jungle, 
are  all  hyper-endemic,  whether  irrigation  be  present  or  not;  in  these 
situations  favorable  breeding  grounds  with  ample  shade  exist." 

These  observations  have  an  important  bearing  upon  the  question  of 
malarial  frequency  in  the  rice-producing  areas  of  our  Southern  States.* 
The  general  experience  even  in  irrigated  areas  has  been  far  from  dis- 
tinctly unfavorable.  Exceptions  no  doubt  are  met  with,  but  as  a  general 
rule  malaria  is  not  of  extraordinary  frequency  on  the  rice  lands  of 
Louisiana  and  southern  Texas.  The  reasons  are  to  be  found  in  the 
foregoing  explanation  that  our  Southern  lowlands  are  probably  not  as 
favorable  to  the  breeding  of  malaria-carrying  mosquitoes  as  the  rice 

•Important  references  to  the  health  of  the  rice-producing  areas  of  South  Carolina  and  Georgia  during  the 
period  when  active  operations  were  carried  on  occur  in  Fenner's  Southern  Medical  Reports  (New  Orleans  and 
New  York,  1849-1850).  One  of  the  most  interesting  articles  is  by  Thomas  Y.  Simmons,  M.  D.,  on  Observations 
on  the  Fever  which  has  Developed  in  the  City  of  Charleston  after  exposure  to  the  country  air  during  the  summer 
and  autumn,  which  is  commonly  called  "country  fever."  See,  also,  a  report  on  "The  Climatology  and  Epidemics 
of  South  Carolina,"  contributed  to  the  Transactions  of  the  American  Medical  Association,  by  Dr.  Manning 
Simmons,  of  Charleston,  in  1872. 

59 


tracts  of  the  Central  Provinces  of  India.*  All  that  has  reference  to 
conditions  of  living,  such  as  better  housing,  effective  screening,  surface 
drainage  in  the  immediate  vicinity  of  the  homes,  nourishing  food, 
medical  attendance,  etc.,  is,  of  course,  of  a  higher  standard  in  this 
country.  No  thorough  investigation,  however,  has  been  made  to 
ascertain  the  relation  which  unquestionably  exists  between  artificial 
irrigation  in  our  rice-producing  sections  and  the  degree  of  malarial 
intensity.  The  conclusions  advanced  with  reference  to  the  rice-pro- 
ducing areas  of  Central  India  are  therefore  of  both  scientific  and  prac- 
tical application  to  the  problem  of  malaria  eradication  in  this  country. 
The  conclusions  advanced  by  Major  Kenrick  read  that 

We  are  justified  in  concluding  that  rice  cultivation  as  carried  out  in  tlie 
Central  Provinces  is  harmful  under  certain  conditions  only,  viz.,  when  accom- 
panied by  irrigation  in  thickly  wooded  areas,  or  in  the  neighborhood  of  jungle, 
or  of  waste  land  covered  by  long  grass  or  scrub,  near  jungle,  in  other  words,  with 
irrigation  and  shade. 

MALARIA  ADVISORY  BOARD  OF  THE  STRAITS 
SETTLEMENTS 

Among  other  foreign  reports  on  malaria  eradication  to  which  more 
extended  references  might  have  been  made  on  this  occasion,  but  which 
can  only  be  very  briefly  referred  to,  is  the  Report  of  the  Malaria 
Advisory  Board  of  the  Federated  Malay  States  for  the  Year  1913,  t 
which  includes  an  excellent  map,  showing  the  area  protected  by  Gov- 
ernment antimalarial  work,  the  swamps  which  are  being  filled  in  by  the 
Department  of  Public  Works,  and,  finally,  antimalarial  drainage  work 
by  private  persons.  In  addition,  the  report  contains  a  chart  exhibit- 
ing the  corrected  total  death  rate  and  the  corrected  malaria  death 
rate  in  correlation  to  the  monthly  rainfall  for  the  period  1907-1913. 
This  chart,  however,  is  limited  to  the  data  for  Kuala  Lumpur 
Town,  but  the  return  is  amplified  by  a  chart  showing  the  percentage 
of  Indian  recruits  at  police  departments  detained  in  hospital  or  given 
sick  leave  for  malaria  each  month  during  the  four  years  1910-1914. 
The  statistical  evidence  is  readily  convincing  that  the  work  of  the 
Advisory  Board  has  been  effective  and  that  malarial  diseases  are  under 

•Soil  Survey  of  Acadia  Parish,  Louisiana,  by  Thomas  D.  Rice  and  Lewis  Griswold,  U.  S.  Department  of 
Agriculture,  Washington,  1904,  Soil  Survey  of  the  Lake  Charles  Area,  Louisiana,  by  W.H.Heileman  and  Louis 
Mesmer,  U.  S.  Department  of  Agriculture,  Washington,  1901,  Soil  Survey  of  Jefferson  County,  Texas,  by 
William  T.  Carter,  Jr.,  L.  R.  Schoenmann,  T.  M.  Bushnell  and  E.  T.  Maxon,  U.  S.  Department  of  Agriculture, 
Washington,  1915. 

tReport  of  the  Malaria  Advisory  Board  of  the  Federated  Malay  States  for  the  Year  1913,  Kuala  Lumpur, 
1914.  "" 

60 


control,  with  a  definite  tendency  towards  a  material  decline.  Thus,  for 
illustration,  the  corrected  malaria  death  rate  for  Kuala  Lumpur  Town 
was  9.7  per  1,000  during  1907,  and  10.7  during  1908;  decreasing  to 
7.7  during  1909;  increasing  to  9.8  during  1910,  and  9.9  during  1911; 
but  decreasing  to  5.8  during  1912,  and  4.2  during  1913.  It  is  regret- 
table that  no  later  data  should  be  available  at  the  present  time.  It 
is  of  interest,  however,  to  note  that  the  average  monthly  percentage 
of  cases  of  malaria  treated  in  the  hospital  or  given  sick  leave,  which 
apparently  has  reference  exclusively  to  Indian  recruits  brought  in  under 
labor  contracts,  increased  from  35.75  per  cent,  in  1910  to  57.01  per  cent, 
in  1911,  decreasing  to  27.33  per  cent,  in  1912  and  to  11.3  per  cent,  in 
1913.  It  is  pointed  out  in  explanation  of  the  statistics  that  "these 
figures  mean  that  in  1911,  to  take  the  worst  case,  every  Indian  at  the 
depot  was  in  hospital  or  given  sick  leave  for  malaria  on  an  average  seven 
times  during  the  year.  Very  few  places  can  show  a  sickness  rate  to 
compare  with  this,  and  when  it  is  remembered  that  the  men  are  picked 
healthy  Sikhs  and  Pathans*  of  a  high  physical  standard  it  will  be 
realized  what  the  condition  of  a  labor  force  having  a  poor  physical 
standard  would  have  been  under  the  circumstances.  It  may  be  men- 
tioned that  the  improvement  was  obtained  notwithstanding  the  large 
increase  in  the  density  of  the  population  at  the  depot  subsequently  to 
1911  when  in  consequence  a  large  number  of  men  were  without  the 
protection  of  a  mosquito  net  at  night.  Quinine  has  only  been  given  to 
men  under  hospital  treatment  or  to  those  who  come  to  ask  for  it."  The 
improvement  was  therefore  chiefly,  if  not  exclusively,  due  to  the 
drainage  work  undertaken  by  the  Government  or  private  enterprise, 
and  the  only  malaria  continuing  consists  apparently  of  cases  in  the 
neighborhood  of  the  swamps  within  the  town  area,  which  were  being 
filled  in  at  the  time,  and  on  the  limits  of  the  area  from  which  the 
disease  had  practically  been  eliminated.  The  conclusion  is  therefore 
justified  that  "in  the  light  of  the  large  reduction  in  malarial  sickness 
following  the  measures  undertaken  and  the  rational  nature  of  the 
procedure  which  has  been  adopted  it  may  be  considered  that  the  case 
for  the  benefit  to  be  obtained  from  anti-malarial  drainage  well  carried 
out  has  been  completely  proved,  and  the  Board  has  every  reason  to  be 
satisfied  that  its  policy  is  entirely  justified  in  this  respect."t 

•For  an  account  of  the  Pathan  tribe,  see  "Ethnography  of  India,"  by  Risley,  Census  of  India,  1901, 
Vol.  I,  Calcutta,  1903.  A  recent  descriptive  account  of  the  Sikhs  has  been  reprinted  in  the  Scientific  Ameri- 
can Supplement,  No.  2204,  for  March  30, 1918. 

tExceptionally  helpful  in  the  study  of  methods  of  malaria  investigation  are  the  reports  of  the  Government  of 
India,  especially  the  following:   Scientific  Memoir  No.  2,  "Malaria  in  India,"  by  Captain  S.  P.  James,  Calcutta. 

61 


NEW  METHODS  OF  EDUCATIONAL  PROPAGANDA 

Aside  from  drainage  measures,  however,  it  is  self-evident  that  malaria 
prophylaxis  in  other  directions  was  also  carried  out  with  a  reasonable 
degree  of  thoroughness.  Quinine  prophylaxis  seems  to  have  been  made 
use  of  to  only  a  very  limited  extent,  and  possibly  not  further  than  in  the 
actual  treatment  of  the  disease.  Much  has  been  done  throughout  India, 
Ceylon  and  Burma  in  the  education  of  the  natives  with  regard  to  the 
essential  facts  of  the  transmission  of  malaria  through  the  anopheline 
mosquito.*  Large  posters,  for  illustration,  are  made  use  of  in  the 
Karachi  Municipality,  signed  by  the  Health  Officer,  Dr.  E.  D.  Shroff, 
who  emphasizes  four  essentials: 

1  BEWARE  OF  MOSQUITOES. 

2  To  harbour  mosquitoes  is  to  court  Malaria. 

3  That  Malaria  is  propagated  from  Man  to  Man  by  Mosquitoes ;  and 

4  That  the  disease  is  preventable. 

The  factors  of  prevention  are  set  forth  briefly,  as  follows: 

(a)  Remove  all  water-holding  tins,  bottles  and  similar  odds  and  ends,  no  mat- 
ter how  small  or  trivial; 

(b)  Properly  cover  all  cisterns,  wells,  tanks,  etc.,  so  as  to  prevent  the  access  of 
mosquitoes  to  water; 

(c)  Sprinkle  Pesterine  or  Kerosine  oil  once  a  week  on  every  collection  of  wast© 
water ; 

(d)  Take  Quinine  regularly;  and 

(e)  Use  Mosquito  Nets. 

This  admirable  poster  is  amplified  by  the  following  hints  for  the  pre- 
vention of  malarial  fevers,  which  are  given  in  full  as  an  illustration 
of  the  thoroughness  with  which  the  work  of  mosquito  extermination 
and  malaria  eradication  is  carried  on  in  the  Municipality  of  Karachi  at 
the  present  time. 

1902,  Scientific  Memoir  No.  46,  "Malaria  in  the  Punjab,"  by  Major  S.  R.  Christophers,  Calcutta,  1911,  Scientific 
Memoir  No.  6,  First  Report  of  the  Anti-Malarial  Operations  at  Mian  Mir,  1901-1903,  by  Captain  S.  P.  James, 
Calcutta,  1903,  followed  in  1904  by  Scientific  Memoir  No.  9,  Second  Report  of  the  Anti-Malarial  Operations  at 
Mian  Mir,  1901-1903. 

The  causes  of  the  apparent  failure  of  the  Mian  Mir  eradication  measures  are  fully  understood  by  those 
thoroughly  familiar  with  all  the  facts.  An  exceptionally  instructive  discussion  of  "The  Lessons  of  Mian  Mir" 
was  contributed  to  the  Journal  of  Tropical  Medicine  and  Hygiene,  under  date  of  May  16, 1910.  It  is  explained 
'n  this  discussion  that  "On  account,  however,  of  its  large  extent,  the  place  was  very  unsuited  for  experimental 
work;  as,  to  be  of  any  use,  each  tentative  operation  must  necessarily  be  extremely  expensive,  and  so  the  initial 
error  was  made  of  dealing  with  a  small  plot  only,  leaving  the  contiguous  area  untouched."  It  is,  however, 
maintained  that  in  consequence  of  the  measures  adopted  at  Mian  Mir  the  incidence  of  malaria  was  reduced  to 
one-third  of  its  previous  average  intensity. 

*An  interesting  circular  entitled  "Some  Facts  About  Malaria,"  with  illustrations,  has  been  issued  by  the 
Mississippi  State  Board  of  Health,  in  cooperation  with  the  International  Health  Board,  in  the  furtherance  of  an 
antimalaria  campaign  in  Bolivar  County,  Mississippi.  The  main  object  of  the  circular  is  to  emphasize  the 
practical  value  of  quinine  treatment  and  prophylaxis. 

62 


MALARIA-PREVENTION  RULES  AND  REGULATIONS  OF  THE 
MUNICIPALITY  OF  KARACHI,  BOMBAY  PRESIDENCY 

INDIA 

It  is  the  duty  of  every  one  employing  labour: 

1  To  improve  the  condition  of  their  servants'  houses  and  to  see  that  they  are 
not  unduly  crowded. 

2  To  see  that  their  compounds  and  the  surroundings  of  their  houses  are  kept 
as  clean  as  possible,  special  attention  being  paid  to  the  clearing  away  of  old  tin 
pots  and  pans,  rank  vegetation,  manure  and  refuse. 

3  To  fill  up  or  drain  all  small  pools,  ponds  and  collections  of  stagnant  water 
near  their  houses. 

4  To  see  that  all  cisterns  and  tanks  and  weUs  are  properly  covered.  The 
Malaria  Parasite  is  conveyed  by  a  species  of  mosquito. 

PRECAUTIONS  TO  BE  TAKEN  INSIDE  THE  HOUSE 

1  The  proper  use  of  the  mosquito  net  is  the  best  and  surest  prophylactic 
measure  that  we  have.  The  net  should  be  of  a  small  mesh  and  should  be  tucked 
in  carefuUy  all  round  the  bed.     If  rods  are  used  it  should  be  hung  inside  them. 

2  During  the  rains  and  whenever  fever  is  prevalent,  each  member  of  your 
household,  including  your  servants,  should  get  15  grains  of  quinine  a  week. 
The  money  will  be  well  spent,  in  that  it  prevents  fever  occurring  among  the 
members  of  your  household  and  being  conveyed  to  others  by  the  mosquitoes. 

3  The  general  cleanliness  of  your  house  should  receive  much  attention.  It  is 
found  that  mosquitoes  rest  in  dark  and  dusty  corners.  The  cleaner  the  house 
the  fewer  the  mosquitoes.  Bins  or  boxes  should  be  provided  for  household 
refuse;  the  refuse  will  be  removed  by  the  Health  Department. 

4  It  is  advisable  to  have  as  few  curtains  and  as  little  drapery  as  possible,  as 
they  harbour  mosquitoes.  Curtains  should  be  light  in  color  and  of  a  washable 
material. 

5  With  regard  to  children  on  their  going  to  bed,  it  is  advisable  to  anoint  their 
legs,  arms,  foreheads  and  necks  with  oil  of  eucalyptus,  or  menthol  and  vaseline 
or  carbolic  oil,  and  also  when  washing  them,  to  use  turpentine  soap,  as  such 
m.easures  tend  to  keep  off  mosquitoes. 

6  Careful  attention  should  be  paid  to  water  receptacles  in  bathrooms,  and 
around  the  house.  It  is  not  advisable  to  keep  "gurrahs"  or  "chatties"  full  of 
water  in  a  bathroom.  Those  in  use  should  be  emptied  daily.  Special  attention 
should  be  paid  to  the  "gurrahs,"  kept  for  cooling  soda  water,  and  shallow  trays 
filled  with  water,  placed  under  the  legs  of  meat-safes  and  sideboards. 

PRECAUTIONS  TO  BE  TAKEN  OUTSIDE   THE  HOUSE 

1  Small  "kutcha"  ponds  and  ditches  exist  in  many  gardens  and  compounds 
and  are  generally  the  breeding  places  of  mosquitoes,  which  when  mature  readily 
fly  into  the  house.  Therefore,  one  of  your  first  measures  should  be  to  have  all 
ponds  and  ditches  near  your  house  filled  up. 

63 


2  Frequently,  there  lie  near  the  kitchen  and  outhouse  old  pots,  kerosine  tins, 
and  other  receptacles  for  water;  a  careful  search  for  these  should  be  made  and,  if 
found,  they  should  be  removed  or  destroyed. 

3  If  there  is  any  well,  it  should  be  protected  by  a  close  fitting  cover. 

4  The  system  of  flower  garden  irrigation  tends  to  form  pools  where  mosquitoes 
can  breed.  It  should  not  therefore  be  carried  out  close  to  the  house,  and  any 
small  tanks  or  reservoirs  in  the  garden  when  not  in  use  should  be  treated  with 
half  a  tumblerful  of  crude  Petroleum  Pesterine  once  a  week,  as  this  procedure 
stops  the  development  of  mosquitoes  in  them.  All  garden  irrigation  should  be 
carried  out  by  means  of  "pukka"  masonry  channels. 

5  Excessive  vegetation  and  undergrowth  should  not  be  allowed  to  exist  near 
the  house.  Anopheles  mosquitoes  prefer  cool,  dark  places  for  resting  in  during 
the  day,  so  that  excessive  vegetation  should  be  cleared  away  from  near  the 
doors  and  windows  of  sleeping  rooms. 

6  It  is  important  to  pay  attention  to  the  cleanliness  of  your  servants'  houses 
and  their  vicinity.  Native  servants  frequently  suffer  from  fever,  and  mosquitoes 
haunt  their  dark  iU- ventilated  houses.     The  following  points  need  attention: 

1  There  is  frequently  a  ditch  or  pond  near  the  servants'  house,  where  the 
mosquitoes  breed.     This  should  be  searched  for  and  filled  up. 

2  The  houses  of  servants,  especially  menial  servants,  syces  and  mallies, 
are  frequently  overcrowded.  As  few  servants  as  possible  should  be  allowed 
to  live  in  the  compound. 

3  Servants'  houses  should  be  thoroughly  cleaned  out  and  whitewashed 
twice  a  year.  Personal  attention  to  the  surroundings  of  your  servants  will 
well  repay  the  trouble,  as  you  will  not  only  have  healthier  and  happier 
servants,  but  the  members  of  your  family  will  run  less  risk  of  catching  fever. 

MALARIAL  FEVER  IS  CONVEYED  BY  ANOPHELES  MOSQUITOES 

AFTER  BITING  A  PERSON  SUFFERING  FROM 

MALARIAL  FEVER 

The  mosqmto  lays  eggs  on  any  accumulation  of  water,  however  small,  inside 
or  outside  the  house,  water  in  wells,  empty  flower  pots,  roadside  pools,  catch- 
pits,  choked  gutters,  etc. 

The  Eggs  look  like  pieces  of  soot  on  the  water. 

The  Eggs  hatch  out  into  Larvae  in  48  hours. 

The  Larvae  look  like  small  pieces  of  stick  lying  on  the  water  until  disturbed 
when  they  swim  away  backwards  and  sink  to  the  bottom. 

The  Larvae  become  Pupae  within  a  week. 

The  Pupae  become  Mosquitoes  about  48  hours  afterwards. 

The  Mosqmto  flies  away  to  suck  the  blood  of  man  or  animal  and  returns  to 
some  water  to  lay  eggs  every  few  days,  depositing  several  hundreds. 

If  the  Mosqmto  sucks  the  blood  of  a  person  suffering  from  Malaria  and  bites  a 
healthy  person,  the  disease  is  conveyed,  and  twelve  days  after  the  healthy  person 
may  take  an  attack  of  fever. 

64 


Precautions: — Prevent  the  Mosquito  breeding  by  getting  rid  of  accumulations 
of  water.  Prevent  the  access  of  Mosquitoes  to  the  water,  or  use  Pesterine  or 
Crude  Petroleum  to  sprinkle  over  the  water  every  seven  days.  Take  fifteen 
grains  of  quinine  weekly,  and  give  fifteen  grains  of  quinine  weekly  to  your 
servants  and  children,  during  the  malaria  season. 
Public  Health  Department, 

E.  D.  Shroff, 
Karach'  Municipality,  L.  R.  C.  P.  &  S.  E.,  D.  P.  H.  (London) 

Health  Officer. 
Karachi,  April  1,  1914. 

ERADICATION  MEASURES  IN  ARGENTINA 

The  urgency  of  antimalarial  measures  is  also,  to  an  increasing  extent, 
being  recognized  in  Central  and  South  America.  In  the  front  rank  of 
practical  eradication  efforts  reference  requires  to  be  made  to  the  ad- 
mirable efforts  of  the  Department  of  National  Hygiene  of  the  Republic 
of  Argentina.  A  valuable  report,  of  nearly  four  hundred  pages,  on 
malaria,  including  numerous  illustrations,  maps  and  diagrams,  prepared 
by  Drs.  Jose  Penna  and  Antonio  Barbieri,  was  published  by  the  Depart- 
ment of  the  Interior  of  the  Republic  of  Argentina  in  1916  {El  Paludismo 
y  su  Profilaxis  en  la  Argentina) .  This  report  is  in  continuation  of  at 
least  two  previous  important  communications  on  the  same  subject 
issued  by  the  Government  of  Argentina  in  1912  and  1915.*  The 
Provinces  of  Argentina,  parts  of  which  are  especially  affected  by  malaria 
and  in  which  antimalarial  work  has  been  carried  on  during  the  last  five 
years  or  more,  are  Tucuman,  Salta,  Jujuy,  Catamarca,  La  Rioja  and 
Santiago  del  Estero.  In  this  rather  remote  region  of  the  Argentine 
Republic,  more  or  less  contiguous  to  the  eastern  foothills  of  the  Andes, 
the  highest  rate  of  malaria  morbidity  occurs  in  the  central  part  of  the 
Province  of  Salta,  where  the  rate  is  246.7  per  1,000.  The  lowest  rate 
of  incidence  in  the  affected  area  (39.6  per  1,000)  occurs  in  the  Province 
of  La  Rioja,  located  in  the  southern  extremity  of  the  malaria  belt,  and 
about  the  same  rate  prevails  in  the  northeastern  portion  of  the  Province 
of  Salta.  Broadly  speaking,  the  relative  frequency  of  malaria  in 
Argentina  decreases  from  the  north  to  the  south,  or  in  conformity  to 
diminishing  temperature.  The  area  affected  by  malaria  represents 
approximately  one-eighth  of  the  total  area  of  the  Republic  of  Argentina. 
The  estimated  number  of  inhabitants  of  this  area  is  about  one 
million,  which  is  also  equivalent  to  about  one-eighth  of  the  estimated 
population  of  Argentina  for  the  year  1914, 

•La  campana  antipaludica  en  la  Republica  Argentina,  Su  Estado  Actual.  Memoria  Informativa  de  la 
Campana  Antipaludica,  durante  el  Ano  1914. 

65 


ARGENTINA  MALARIA  MORBIDITY  STATISTICS 

It  is  explained  in  the  report  referred  to  that  the  mountainous  regions 
of  the  north  are  almost  ideal  for  the  propagation  of  mosquitoes,  and, 
consequently,  the  spread  of  malaria.  In  this  respect  there  seems  to  be  a 
similarity  with  the  conditions  in  northern  India,  so  admirably  reported 
upon  by  Major  Leonard  Rogers  {Fevers  of  the  Tropics)*  and  Major 
Ken  rick  for  the  Central  Provinces  of  India.  The  rivers  which  flow 
from  the  Andes  Mountains  frequently  during  the  thawing  season  or 
after  heavy  rains  inundate  the  lower  valleys,  the  soil  of  which  consists 
of  an  impervious  stratum  of  clay,  f  giving  rise  to  wide-spread  stagnation 
during  the  spring  and  autumn  months.  Local  problems  are  rather 
difficult  of  exact  interpretation  without  the  aid  of  maps  showing  the 
details  of  the  topography,  but  the  table  below  will  serve  the  present 
purpose  of  emphasizing  the  wide  range  in  local  prevalence  in  the  five 
most  affected  provinces  of  the  Republic  of  Argentina,  during  the  four 
years  1912-1915.  During  this  period  there  were  521,361  cases  of 
malaria,  equivalent  to  a  morbidity  rate  of  186.7  per  1,000  for  the  five 
provinces  combined. J 

MALARIA  MORBIDITY  IN  THE  ARGENTINE  REPUBLIC 


1912-1915 


Aggregate 
Provinces      Population 
1912-15 

Tucuman  .  1,339,506 

Salta 591,483 

Jujuy 231,610 

Catamarca  319,618 

LaRioja..  310,000 


Total        2,792,217 
Per  cent. 


Jan.,  Feb., 
March 

60,803 

34,714 

14,073 

9,165 

2,357 

121,112 
23.2 


Apr.,  May, 
June 

85,043 
41,502 
14,960 
11,960 

3,287 

156,752 
30.1 


July,  Aug., 
Sept. 

56,321 
35,243 
12,858 
11,936 
3,105 

119,463 


Oct.,  Nov., 
Dec. 


60,266 
35,837 
13,976 
10,586 
3,369 

124,034 
23.8 


Total 

262,433 

147,296 

55,867 

43,647 

12,118 

521,361 
100.0 


Morbidity 

Rate  per 

1,000 

Inhabitants 

193.8 

246.7 

242.7 

142.8 

39.6 


186.7 


Of  the  521,361  cases,  23.2  per  cent,  occurred  during  the  first  quarter  of 
the  year;  30.1  per  cent.,  during  the  second;  22.9  per  cent.,  during  the 
third  and  23.8  per  cent.,  during  the  fourth.    The  months  of  April,  May 

*This  is  a  monumental  work  rarely  accessible  to  the  student  of  the  subject  in  this  country.  The  title  of  the 
treatise  is  "Fevers  in  the  Tropics,  Their  Clinical  and  Microscopical  Differentiation,  including  the  Milroy 
Lectures  on  Kala-Azar,"  by  Leonard  Rogers,  M.  D.,  F.  R.  C.  P.,  F.  R.  C.  S.,  B.  S.,  I.  M.  S.,  London,  1908. 

fThe  correlation  of  a  high  degree  of  malaria  frequency  to  soil  conditions  is  best  illustrated  in  the  Yazoo 
Delta  of  Mississippi.  The  typical  soil  formation  is  the  Sharkey  clay  and  the  Yazoo  clay,  which  are  practi- 
cally impervious  and  therefore  retain  surface  water  for  long  periods  of  time. 

JFor  the  Delta  Counties  of  Mississippi  the  corresponding  average  malaria  morbidity  rate  is  247.7  for  the 
white  population  and  135.0  per  100,000  for  the  colored.     See,  also,  table  on  page  23. 


66 


and  June  are  therefore  the  most  malarial,  corresponding  to  the  reversed 
cHmatological  conditions  of  the  southern  hemisphere.  In  the  five 
provinces,  about  one-half,  or  51.1  per  cent.,  of  all  the  cases  occurred  in 
the  Province  of  Tucuman.  To  facilitate  an  understanding  of  the  local 
climatological  conditions,  the  table  following  shows,  by  seasons,  the 
comparative  temperature,  the  rainfall  and  the  relative  humidity  of  the 
city  of  Tucuman,  the  city  of  Buenos  Aires  and  the  city  of  New  Orleans. 

COMPARATIVE  TEMPERATURE,  RAINFALL  AND  HUMIDITY 

(Temperature,  Degrees  Fahrenheit) 

Q-f      t  January  to  April  to  July  to  October  to  Y 

March  June  September  December  I  ear 

Tucuman 74.4  58.5  57.2  72.3  65.6 

Buenos  Aires 72.6  56.4  53.1  67.0  62.2 

New  Orleans 61.3  75.2  81.5  63.0  70.3 

Rainfall  (Inches) 

Tucuman 19.1               6.3  1.3  11.7  38.4 

Buenos  Aires 10.2              8.6  7.6  10.4  36.8 

New  Orleans 11.0             19.2  20.5  10.3  61.0 

Humidity  (Per  Cent.) 

Tucuman 77  82  70  70  75 

Buenos  Aires 72  83  80  71  77 

New  Orleans 78  75  81  78  78 

According  to  this  table  the  highest  average  temperature  in  the  city 
of  Tucuman  prevails  during  January-March,  which  coincides  with  the 
highest  rainfall.  The  temperature  is  considerably  less  during  the 
months  April,  May  and  June,  when  the  morbidity  from  malaria  reaches 
a  maximum.  During  these  months  the  rainfall  was  less  than  one- third 
of  that  of  the  preceding  three  months,  but  the  humidity  reaches  a  maxi- 
mum of  82.1  per  cent.  Compared  with  Buenos  Aires,  the  temperature 
conditions  are  somewhat  but  not  materially  higher  than  in  Tucuman. 
The  rainfall  is  about  the  same,  but  more  evenly  distributed  throughout 
the  year.  The  humidity  is  higher  during  the  first  three  months  of  the 
year,  but  lower  during  the  remainder.  Compared  with  New  Orleans 
the  climatological  conditions  at  Tucuman  are  apparently  much  more 
favorable,  in  that  for  the  different  seasons  the  aveiage  temperature,  the 
average  rainfall  and  the  average  humidity  are  nearly  all  distinctly  lower 

67 


in  the  city  of  Tucuman.  In  addition  thereto,  the  elevation  at  Tucuman 
is  1,480  feet,  against  sea-level  at  New  Orleans.  The  predisposing  con- 
ditions are  therefore  unquestionably  more  decidedly  local  or  topo- 
graphic, or  physiographic,  as  the  case  may  be,  rather  than  climatological. 
The  average  malaria  mortality  rate  of  New  Orleans  for  the  five-year 
period  1912-1915  was  8.4  per  100,000,  in  comparison  with  a  rate  of  25.9 
for  the  city  of  Tucuman.  The  general  mortality  of  the  Province  of 
Tucuman,  from  all  causes,  during  the  decade  ending  with  1910  was  25.9 
per  1,000  of  population,  but  a  maximum  death  rate  of  32.5  per  1,000 
prevailed  during  the  months  of  October,  November  and  December. 
The  predominating  causes  are  stomach  and  intestinal  disease,  pneumonia, 
nervous  disorders  and  tuberculosis. 

Impressed,  unquestionably,  with  the  facts  disclosed  by  the  malaria 
morbidity  statistics  of  the  northwestern  provinces  of  the  republic,  the 
Argentine  Government  called  a  National  Medical  Conference  to  consider 
the  question  and  make  recommendations  with  reference  thereto.  As  a 
first  and  essential  step  the  Government  enacted  a  law  declaring  malaria 
a  notifiable  disease  and  provided  for  free  medical  treatment,  the  free 
distribution  of  quinine,  educational  campaigns,  the  scientific  study 
of  preventive  measures,  the  undertaking  of  sanitary  engineering  works 
and  the  establishment  of  laboratories  in  the  principal  cities.  In  addi- 
tion thereto,  a  technical  statistical  oflSce  was  organized  and  active 
work  was  commenced  in  1911.  Sanitary  engineers  were  sent  into  the 
different  infected  provinces,  for  the  purpose  of  first  ascertaining  the  local 
conditions,  and  the  required  initial  procedure  included  observations  upon 
the  probable  quantity  of  quinine  required  and  the  installation  of  labora- 
tories for  blood  examination,  etc.  The  entire  administration  of  the 
work  was  placed  under  the  National  Board  of  Health.  Inspectors  were 
assigned  to  the  different  sections  most  seriously  affected  with  malaria, 
and  regular  tours  of  investigation  were  made  at  intervals  of  four  months, 
frequently  under  great  difficulties,  on  horseback  in  the  more  remote  and 
sparsely  settled  sections.  To  and  iticluding  the  year  1914  the  quantity 
of  quinine  distributed  amounted  to  1,032,924  grams,  of  which  87,000 
grams  were  for  prophylactic  purposes.  No  exclusive  reliance,  however, 
was  placed  upon  quinine  prophylaxis,  and  sanitary  engineering  works 
were  introduced  with  excellent  results.  Swamplands  are  being 
drained,  stagnant  pools  are  being  treated  with  petroleum  and  low-lying 
areas  are  being  filled  in,  the  houses  of  malaria  patients  are  being  fumi- 
gated, etc.     It  is  intimated  that  the  Government  could  have  been  more 

68 


liberal  in  its  appropriations,  but  evidently  much  has  been  achieved  in  so 
far  as  the  statistical  evidence  of  malaria  eradication  can  be  considered 
conclusive.  An  important  railway  company  traversing  the  affected 
regions  has  actively  cooperated  with  the  Government  by  giving  preven- 
tive treatment  to  its  employees.*  The  table  following  brings  out  clearly 
the  reduction  in  the  ascertained  infection  of  the  population  of  four  of  the 
principal  affected  provinces  during  the  period  1909-1915. 

PERCENTAGE  OF  MALARIAL  INFECTION  IN  ARGENTINA 
BY  PROVINCES  1909-1915 

TUCUMAN  SALTA  JUJUY  CATAMARCA 

Year  Per  Cent.  Per  Cent.  Per  Cent.  Per  Cent. 

1909 37.7  27.5  19.7  41.7 

1910 31.9  11.2  16.8  46.9 

1912 34.8  15.8  16.5  41.0 

1913 23.9  14.3  13.7  36.2 

1914 13.0  8.2  8.7  39.5 

1915 12.9  5.8  8.2  21.8 

MALARIA  IN  PERU  AND  ECUADOR 

Where  so  much  has  been  done  in  a  remote  region  of  the  Argentine 
Republic  it  may  safely  be  assumed  that  much  antimalarial  work  is  in 
progress  also  in  other  states  and  countries  of  South  and  Central  America, 
for  which  the  information  is  not  so  conveniently  available.  No  report 
has  as  yet  been  made,  for  illustration,  upon  the  plan  initiated  by  the 
Peruvian  Government  in  1916,  and  briefly  referred  to  at  the  time  in  "A 
Plea  and  a  Plan  for  the  Eradication  of  Malaria  Throughout  the  Western 
Hemisphere."  t  There  is,  however,  an  interesting  reference  to  the  ex- 
cessive incidence  of  malaria  in  the  city  of  Guayaquil,  Ecuador,  and 
nearby  territory  in  the  report  of  a  first  expedition  to  South  America  of 
the  Harvard  School  of  Tropical  Medicine.  The  statement  is  made  that 
great  difficulty  was  experienced  in  Guayaquil  in  the  diagnosis  of  yellow 
fever,  since  about  one-third  of  those  admitted  to  the  Yellow  Fever 
Hospital  were  found  to  be  suffering  from  malarial  infection.  The  con- 
clusion is  advanced  that  "the  correct  differential  diagnosis  from  malaria 
upon  clinical  grounds  is  frequently  impossible;  but  on  the  other  hand, 
the  fact  must  be  taken  into  account  that  in  a  city  like  Guayaquil,  where 

•For  the  translation  of  this  important  report  I  am  obliged  to  one  of  my  office  assistants,  Mr.  A.  F.  Schopp. 

t"A  Plea  and  a  Plan  for  the  Eradication  of  Malaria  Throughout  the  Western  Hemisphere,"  by  Frederick  L. 
Hoffman,  Prudential  Press,  Newark,  1916.     (Copies  available  on  request.) 

69 


during  the  year  about  ninety-five  per  cent,  of  the  population  are  said  to 
suffer  from  malaria,  a  concomitant  infection  with  this  disease  and  yellow 
fever  may  likewise  exist,  and  that  even  though  malarial  parasites  may 
be  found  in  the  blood,  nevertheless  the  individual  may  likewise  be  in- 
fected with  yellow  fever."* 

In  a  report  on  a  "Geographical  Reconnaissance  Along  the  Seventy- 
third  Meridian,  including  the  Andes  of  Southern  Peru,"  by  Isaiah 
Bowman,  of  the  American  Geographical  Society,  a  brief  reference 
occurs  to  "the  appalling  mortality  from  malaria"  at  Rosalina,  where 
"over  sixty  Indians  died  of  malaria  in  one  year."  Malaria  has  also 
been  a  matter  of  serious  concern  to  rubber-gatherers  in  the  Peruvian 
forests,  and  "many  of  the  river  villages  have  been  abandoned  in  conse- 
quence of  its  ravages  and  the  disease  has  driven  the  Indians  to  perma- 
nent residence  in  the  hills,  "f 

MALARIA  IN  SWAZILAND  AND  CYPRUS 

A  considerable  amount  of  new  and  most  interesting  information  on 
malaria  in  Africa  has  become  available  during  recent  years,  but  ex- 
tended references  therefrom  would  unduly  enlarge  the  present  discussion. 
Of  exceptional  interest,  however,  is  a  brief  account  of  an  epidemic  of 
malaria  in  Swaziland,  included  in  the  annual  report  of  the  resident 
commissioner,  as  follows:  "The  outstanding  feature  of  the  year  was 
the  unusually  severe  outbreak  of  malaria  which  began  about  the  middle 
of  December,  1916.  It  extended  to  the  highest  parts  of  the  country 
where  it  has  been  found  only  occasionally  before.  Very  virulent  forms 
of  the  disease,  resulting  in  death  after  an  illness  of  from  a  few  hours  to  a 
day  or  two,  were  fairly  common  amongst  the  natives  of  the  low  country. 
Free  quinine  distribution  was  made,  as  usual,  at  the  various  outstations. 
About  the  middle  of  the  summer  there  was  an  exceedingly  virulent 
epidemic  of  bacillary  dysentery  in  the  Hlatikulu  district.  About 
seventy  people  were  affected  and  thirty  of  them  died.  The  epidemic 
was  promptly  taken  in  hand  and  this  succeeded  in  limiting  it  to  a  dozen 
kraals." 

Of  somewhat  earlier  date  is  a  Report  on  the  Prevention  of  Malaria  in 
Cyprus,  by  Sir  Ronald  Ross,  issued  as  a  preliminary  publication  under 

•Report  of  First  Expedition  to  South  America,  1913,  Harvard  School  of  Tropical  Medicine,  Cambridge,1915. 

tAmong  other  references  of  value  on  malaria  in  Brazil  and  its  relation  to  the  exploration,  settlement  and 
economic  development  of  the  country,  see  "Notes  of  a  Botanist  on  the  Amazon  and  Andes,"  by  Richard  Spruce, 
two  volumes,  Macmillan  &  Co.,  London,  1908,  "The  Lower  Amazon,"  by  Algot  Lange,  New  York,  1914,  and 
"Through  the  Brazilian  Wilderness,"  by  Theodore  Roosevelt,  New  York,  1914,  with  special  reference  to  his 
own  illness  (pp.  197-198,  309  and  319-320). 

70 


date  of  January,  1914.  This  report  emphasizes  the  suitability  of  Cyprus 
for  a  large  antinialaria  campaign,  chiefly,  however,  in  the  direction  of 
thoroughly  effective  methods  of  mosquito  extermination.  Sir  Ronald 
Ross  observes  that  the  only  country  which  in  his  opinion  would  lend 
itself  better  to  mosquito  eradication  than  Cyprus  would  be  Ismailia, 
Egypt,  on  account  of  the  absence  of  rainfall  during  the  warm  months  of 
the  year  and  for  other  reasons.  He  considers  the  method  of  quinine 
distribution  "just  as  difficult  in  Cyprus  as  it  is  anywhere  else,  this 
difficulty  depending  upon  the  natural  unwillingness  of  the  people  in 
Cyprus  and  elsewhere  to  take  an  unpleasant  medicine  for  the  rest  of  their 
lives."  He,  nevertheless,  recommends  that  quinine  distribution  should 
be  pushed  with  the  greatest  vigor  amongst  school-children,  especially 
those  with  enlarged  spleen.  He  also  recommends  the  distribution  of 
goldfish  to  all  owners  of  irrigation  systems.  He  ascertained  by  means 
of  an  actual  spleen  survey  that  the  average  spleen  rate  was  25.4  per  cent., 
and  as  high  as  100  per  cent,  in  one  district,  while  it  was  as  low  as  zero  in 
another.  In  the  most  heavily  infected  district  of  Larnaca,  in  which  756 
children  were  examined,  the  spleen  rate  was  49.73  per  cent.  The  report 
by  Sir  Ronald  Ross  is  a  model  of  brevity  combined  with  thoroughness 
and  a  due  regard  of  all  the  essential  factors  affecting  the  incidence  of 
malaria  and  its  prevention  in  the  Island  of  Cyprus.*  Such  reports  should 
be  made  for  every  American  community  or  section  in  which  the  incidence 
of  malaria  is  above  the  normal  average.  It  need  hardly  be  said  in  this 
connection  that  the  conclusions  of  Sir  Ronald  Ross  were  based  chiefly 
upon  microscopical  diagnoses,  and  it  may  be  stated  in  conclusion  that 
out  of  503  cases  microscopically  examined,  470,  or  94.4  per  cent.,  were 
confirmed.  The  distribution  of  the  different  species  of  parasites  was 
tertian,  48.5  per  cent.,  quartan,  8.0  per  cent.,  and  aestivo-autumnal 
(malignant),  43.5  per  cent. 

COMPARATIVE  PAN-AMERICAN  MALARIA  STATISTICS 

The  excessive  incidence  of  malaria  in  certain  sections  of  Central  and 
South  America  is  shown  in  the  following  table,  derived  from  "The 
Mortality  of  the  Western  Hemisphere,"  issued  by  The  Prudential 
Insurance  Company  in  1915.  It  has  not  seemed  necessary  for  the 
present  purpose  to  bring  the  data  down  to  date. 

*0f  special  importance  to  the  student  of  methods  in  malaria  investigation  is  the  report  by  Sir  Ronald  Ross 
on  "Prevention  of  Malaria  in  Mauritius,"  published  by  J.  and  A.  Churchill,  London,  1909. 


71 


COMPARATIVE  MORTALITY  FROM  MALARIA 

Rate  per  Percentage 

10,000  of 

Population  All  Causes 

Nicaragua  (1908-1911) 72.7  40.5 

British  Honduras  (1907-1911) 68.9  27.6 

British  Guiana  (1906-1911) 67.0  20.1 

Para,  Brazil  (1906-1910) 43.7  19.5 

Guayaquil,  Ecuador  (1909-1912) 43.2  8.6 

Panama  Canal  Zone — Civil  Population — 

(1906-1912) 39.2  13.1 

Salvador  (1908-1913) 36.3  13.0 

Venezuela  (1905-1909) 34.9  16.8 

Trinidad-Tobago  (1907-1911) 21.9  9.0 

Argentina  (1907-1911) 15.0  7.0 

Paramaribo,  Dutch  Guiana  (1907-1912) .  .  14.5  4.2 

Saint  Lucia  (1907-1911) 14.0  6.7 

Bahia,  Brazil  (1905-1908) 11.7  6.3 

Porto  Rico  (1904-1908) 11.4  5.0 

This  table  reemphasizes  the  practical  urgency  of  malaria  eradication  as 
a  social  and  economic  problem  of  serious  concern  to  practically  all  the 
important  countries  of  the  Western  Hemisphere.*  The  table  fully 
sustains  the  far-reaching  value  of  the  resolution  unanimously  adopted 
by  the  Second  Pan-American  Scientific  Congress,  as  Article  29  of  the 
Final  Act,  reading  as  follows: 

That  all  American  countries  inaugurate  a  well-considered  plan  of  malaria 
eradication  and  control  based  upon  the  recognition  of  the  principles  that  the 
disease  is  preventable  to  a  much  larger  degree  than  has  thus  far  been  achieved, 
and  that  the  education  of  the  pubUe  in  the  elementary  facts  of  malaria  is  of  the 
first  order  of  importance  to  the  countries  concerned. 

Every  authority  on  malaria  eradication  agrees  that  the  practical 
solution  of  the  question  is  primarily  one  of  active  and  intelligent  co- 
operation on  the  part  of  the  Government  and  the  many-varied  associated 
activities  of  the  general  public.     Regardless  of  the  encouraging  evidence 

*In  view  of  the  special  importance  which  is  properly  attached  to  the  malaria  erperience  in  Panama,  the 
following  statistics  are  of  interest:  From  a  rate  of  31.2  per  10,000  in  1906  the  malaria  mortality  of  white 
employees  in  the  Panama  Canal  Zone  was  reduced  to  2.8  in  1914,  increasing  to  6.4  in  1915;  but  no  deaths 
occurred  during  1916.  The  rate  for  the  colored  employees  during  the  same  period  decreased  from  102.4  in 
1906  to  0.7  in  1916.  In  that  year  there  were  only  2  deaths  from  malaria  among  the  colored  employees.  In  the 
Panama  Canal  Zone  the  number  of  hospital  malaria  cases  for  white  employees  decreased  from  a  maximum  of 
8,071  in  1907,  or  75.4  per  cent,  of  the  employees,  to  only  180  cases  in  1916,  or  4  per  cent.  For  the  colored 
employees  the  number  of  hospital  malaria  cases  decreased  from  16,659  in  1906,  or  79  per  cent.,  to  only  367  cases 
in  1916,  or  1.3  per  cent. 

72 


of  malaria  reduction  in  many  sections  of  the  world,  the  anticipated 
progress  based  upon  the  clear  recognition  of  the  causative  factor  in 
malaria  dissemination  has  not  been  made.  The  work  of  the  National 
Committee  on  Malaria  of  the  United  States  has  been  limited  to  the  dis- 
cussion of  more  or  less  highly  specialized  aspects  of  the  problem  and 
the  encoaragement  of  Federal  and  State  efforts  and  the  admirable 
coordination  of  the  work  of  the  International  Health  Board  in  certain 
localities  in  the  Southern  States.  If  more  rapid  progress  is  to  be  made 
within  a  measurable  period  of  time,  much  more  is  required  than  has 
heretofore  been  the  case.  The  movement  for  malaria  eradication  will 
necessarily  gain  force  in  proportion  as  the  economic  aspects  of  the 
problem  are  more  clearly  realized  and  the  achievements  in  particular 
localities  are  brought  intelligently  to  public  attention.* 

WORKMEN'S  COMPENSATION  FOR  MALARIAL  DISEASES 

An  interesting  case  involving  the  question  of  workmen's  compensa- 
tion for  malarial  diseases  was  decided  by  the  Industrial  Accident  Com- 
mission of  California  (No.  3126,  December  12,  1916).  This  was  the 
case  of  William  Addison  Tennant,  applicant,  versus  State  Department 
of  Engineering,  Flood  Control  Division,  defendant.  Applicant  was  em- 
ployed by  the  defendant  as  chainman  with  a  surv'^eying  party  and 
clai^tned  compensation  for  disability  due  to  malaria  contracted  on  or 
about  September,  1916.  For  three  months  prior  to  this  date  applicant 
had  been  engaged  in  the  survey  of  the  Cosumnes  River,  near  Gait,  and 
the  adjacent  swamp  country,  during  which  time  the  party  used  as 
living-quarters  houseboats  on  the  river,  which  were  furnished  by  the 
defendant.  Mosquitoes  were  very  prevalent  in  this  region,  and  although 
screen  tents  were  used  at  night  for  the  protection  of  the  employees,  the 
testimony  showed  that  the  mosquitoes  could  not  be  kept  out  and  that 
applicant  was  almost  constantly  exposed  to  insect  bites.  It  appeared 
further  that  malaria  was  common  in  this  region,  but  that  no  other 
member  of  the  party  Was  affected  with  it.  The  applicant  attributed  his 
attack  to  the  bites  of  mosquitoes  sustained  while  so  engaged.  The 
commission  held  that  since  the  risk  of  contracting  malarial  fever  was 
not  a  risk  peculiar  to  the  applicant's  employment,  but  was,  a  risk  to 
which  all  persons  residing  in  that  locality  were  subjected,  whether  en- 
gaged as  employees  or  not,  the  evidence  was  not  sufficient  to  establish 
as  a  fact  that  the  injury  arose  out  of  and  was  approximately  caused  by 

•For  a  full  account  of  the  practical  possibilities  of  cooperative  action  in  the  furtherance  of  antimalarial 
measures,  see  my  "A  Plea  and  a  Plan  for  the  Eradication  of  Malaria  Throughout  the  Western  Hemisphere." 

73 


the  employment.     The  defendant  was  accordingly  discharged  from  all 
liability  on  account  of  the  claim  asserted  in  this  proceeding. 

Serious  objections  lie  against  this  decision,  which  certainly  will  hinder 
the  cause  of  malaria  eradication  as  a  matter  of  general  public  and 
corporate  policy.  It  has  been  the  experience  of  the  United  States 
Geological  Survey  that  men  frequently  are  disabled  for  long  periods  of 
time  in  consequence  of  occupational  exposure  to  the  risk  of  malarial  in- 
fection in  the  same  manner  or  under  much  the  same  circumstances  as  set 
forth  in  the  preceding  case.  There  certainly  can  be  no  question  of  doubt 
but  that  in  the  event  of  similar  cases  being  brought  before  the  United 
States  Employees  Compensation  Commission  that  compensation  would 
be  paid  as  a  matter  of  simple  justice,  in  clear  recognition  of  the  occupa- 
tional malaria  hazard  in  connection  with  such  employment,  for  illustra- 
tion, as  levee-construction  on  the  Mississippi  River.  As  a  general 
principle,  the  doctrine  of  compensation  for  occupational  diseases  is  as 
yet  so  imperfectly  developed  in  this  country,  and  practically  not  at  all 
in  the  Southern  States,  where  malaria  prevails  most  extensively,  that 
the  decision  of  the  California  Industrial  Accident  Board  is  not  likely  to 
stand  the  test  of  subsequent  experience. 

The  theory  of  personal  responsibility  for  conditions  predisposing  to 
malaria  was  considered  in  the  United  States  at  least  as  early  as  1810, 
according  to  a  brief  account  of  a  trial  at  law,  in  which  the  influence  of 
water  raised  by  a  mill-dam  on  the  health  of  the  inhabitants  in  the 
neighborhood  was  considered  and  set  forth  in  one  of  the  Memoirs  of  the 
Connecticut  Academy  of  Arts  and  Sciences.  This  trial  was  held  before 
the  Superior  Court  at  Litchfield,  in  January,  1800.  Unfortunately,  the 
evidence  presented  was  so  conflicting  and  the  underlying  factors  of 
disease  transmission  by  the  anopheline  mosquito  being  unknown,  the 
decision  of  the  court  was  adverse  to  the  plaintiff,  and  in  favor  of  the 
owner  of  the  dam,  upon  the  ground  that  the  same  could  not  be  proved 
to  be  a  nuisance.  This  point  of  view,  however,  no  longer  prevails, 
and  to  the  extent  that  suits  of  law  are  brought  against  offending  owners 
violating  local  or  State  ordinance,  the  possibilities  of  more  active 
cooperation  on  the  part  of  the  general  public  in  malaria  eradication  and 
mosquito  extermination  will  be  more  clearly  realized.  There  appear 
to  have  been  no  final  court  decisions  on  the  question  of  personal,  cor- 
porate or  public  responsibility  in  pecuniary  damages  for  malaria  con- 
tracted in  consequence  of  conditions  within  the  definition  of  a  personal 
menace  or  a  public  nuisance  causing  malarial  infection  in  a  serious  or 
fatal  form. 

74 


RECENT  MUNICIPAL  ORDINANCES  ON  LEGAL  REQUIRE- 
MENTS FOR  REPORTING  OF  MALARIAL  DISEASES 

As  a  first  step  in  this  direction,  it  is  clearly  necessary  for  each  and 
every  community  more  or  less  directly  concerned  in  malaria  eradication 
or  mosquito  extermination  to  adopt  ordinances  to  prevent  the  breeding 
of  mosquitoes  and  the  maintaining  of  nuisances  contributory  thereto. 
Among  encouraging  evidences  in  this  direction  are  the  ordinances 
adopted  by  Crystal  City,  Mo.,  under  date  of  January  8,  1916,  the  city 
of  Dallas,  Texas,  under  date  of  July  12,  1916,  and  the  city  of  Tyler, 
Texas,  under  date  of  May  15,  1916.  These  are  reported  in  full  in  the 
annual  survey  of  Municipal  Ordinances,  Rules,  and  Regulations  Per- 
taining to  Public  Health,  issued  by  the  United  States  Public  Health 
Service  during  the  year  1917.*  Of  special  importance  is  a  resolution  of 
the  Board  of  Health  of  the  city  of  New  Orleans,  adopted  March  14, 
1916,  providing  for  the  compulsory  notification  of  malaria,  reading,  in 
part,  "That  from  and  after  this  date  malarial  fever  be  included  in  the 
list  of  communicable  diseases  to  be  reported  to  the  board  of  health  of 
the  city  of  New  Orleans,  and  for  the  parish  of  Orleans."  Malaria  was 
also  included  in  the  list  of  communicable  diseases  required  to  be  notified 
under  an  ordinance  of  the  city  of  North  Yakima,  Washington,  of  April 
10,  1916. 

The  urgency  of  malaria  notification  is  strongly  emphasized  in  the 
recommendations  of  the  Health  Survey  of  Middletown,  Conn.,  by 
David  Greenberg  and  Ira  D.  Joel,  with  an  introduction  by  Prof.  C-E.  A. 
Winslow,  of  the  Department  of  Public  Health,  Yale  School  of  Medicine. 
According  to  Prof.  Winslow's  introduction  "The  problem  of  malaria  in 
Middletown  is  a  serious  one,  as  it  is  in  ma,ny  other  sections  of  Connecti- 
cut. From  one-half  of  the  physicians  interviewed  Mr.  Greenberg  and 
Mr.  Joel  obtained  evidence  of  200  cases  treated  during  the  current  year, 
and  though  malaria  is  rarely  a  cause  of  death,  the  aggregate  amount  of 
sickness  and  disability  which  it  creates  is  a  serious  burden  upon  the 
community.  The  mosquito  problem  of  Middletown  appears  to  be 
mainly  due  to  small  accumulations  of  stagnant  water  and  requires 
supervision  and  treatment  of  these  isolated  spots  rather  than  extensive 
drainage  operations.  It  is  important  that  an  ordinance  should  be 
adopted  declaring  the  exposure  of  cans,  kettles,  bottles,  or  other  un- 
screened receptacles  which  may  furnish  opportunities  for  mosquito 

•State  laws  and  regulations  pertaining  to  Public  Health,  adopted  during  1915,  Municipal  Ordinances, 
Rules,  and  Regulations  pertaining  to  Public  Health,  adopted  during  1913  by  localities  having  a  population  of 
over  ten  thousand  in  1910. 

75 


breeding  to  constitute  a  nuisance."  These  observations  are  amplified 
by  a  concluding  statement  in  the  survey  that  "Malaria  is  a  communi- 
cable disease,  communicated  from  person  to  person  through  the  bite  of 
the  malaria  mosquito.  To  restrict  the  spread  of  this  infection  it  must 
be  treated  like  any  other  such  disease,  and  hence  we  recommend  as 
Recommendation  No.  12,  That  malaria  be  made  a  reportable  disease." 

The  occurrence  of  malaria  in  Connecticut  is  a  matter  of  exceptional 
historical,  medical  and  sanitary  interest.  The  subject  was  referred  to 
in  the  "Climatology  of  the  United  States,"  by  Lorin  Blodget  (Phila- 
delphia, 1857),  who  remarks  that  "The  fact  that  there  is  now  little  or 
none  of  fever  and  ague  in  the  Connecticut  Valley  and  on  the  New  Eng- 
land Coast  is  no  disproof  of  its  climatological  adaptation  to  it,  if  local 
circumstainces  are  favorable.  Dr.  Forry  quotes  from  Dr.  Holmes'  Prize 
Dissertion  on  the  Intermittent  Fever  of  New  England  proof  that  inter- 
mittent fever  has  prevailed  on  the  Connecticut  River  from  our  earliest 
colonial  history." 

In  1887  Dr.  Franklin  C.  Clark,  of  Providence,  R.  I.,  contributed  an 
interesting  discussion  of  "Travels  of  Intermittent  Fever  in  Rhode 
Island"  to  the  Ninth  Annual  Report  of  the  Rhode  Island  State  Board  of 
Health.  In  it  reference  is  made  to  an  outbreak  of  "a  pestilential  fever" 
which  visited  the  colony  of  Massachusetts  in  1633,  which  was  attributed 
to  large  swarms  of  "humming  flies."  The  discussion  is  illustrated  by  an 
exceptionally  valuable  map  indicative  of  the  gradual  progress  of  the 
disease  into  new  sections  of  the  State,  commencing  with  the  outbreak 
of  1723  and  continuing  with  the  two  most  important  outbreaks  of  1830- 
1840  and  1880-1881.  According  to  the  Nineteenth  Annual  Report  of 
the  Rhode  Island  State  Board  of  Health  for  1895,  public  attention  was 
directed  to  the  prevalence  of  malarial  diseases  in  the  public  schools  of 
certain  sections,  and  through  the  spring  and  early  summer  of  that  year 
frequent  complaints  had  been  heard  from  physicians  and  others  in  regard 
to  the  unusual  amount  of  malarial  disease,  and  "because  of  the  inter- 
ference of  malarial  sickness  with  school  work,"  an  investigation  was 
made  of  the  number  of  cases  in  the  different  schools  of  Providence,  and 
656  cases  were  ascertained,  with,  however,  a  reasonable  question  of 
doubt  as  to  the  accuracy  of  the  diagnosis,  involving  possibly  erroneous 
reporting  of  cases  of  typhoid  fever. 

Still  more  interesting  as  evidence  of  the  present-day  importance  of 
malaria  in  certain  New  England  States  and  the  danger  of  local  outbreaks 
in  epidemic  form  is  the  following  extract  from  the  report  of  the  Thirty- 
third  Report  of  the  State  Board  of  Health  of  Connecticut,  for  the  two 

76 


years  ending  September  30, 1914 :  "An  interesting  fact  is  that,  previously 
to  the  Civil  War,  malaria  had  been  for  a  long  period  almost  unknown 
within  the  borders  of  the  state.  It  appears  to  have  been  brought  north 
by  the  soldiers  returning  from  the  war  and  was  then  carried  by  the 
Anopheles  mosquitoes  here  present  to  almost  every  inhabited  part  of  the 
state.  It  was  very  prevalent  in  the  seventies  and  then  gradually  sub- 
sided. The  reports  of  the  Town  Health  Officers  indicate  that  it  has 
been  more  common  again  during  the  past  two  or  three  years,  particularly 
in  the  southern  and  southwestern  parts  of  the  state,  and  possibly  the 
Italian  immigrant  has  had  something  to  do  with  its  reappearance. 
Greenwich  has  been  one  of  the  principal  sufferers  and  in  1912  the  number 
of  cases  was  estimated  at  about  nine  hundred.  A  house  to  house  can- 
vass for  cases  and  a  vigorous  anti-mosquito  campaign  has  caused  it  to 
almost  entirely  disappear,  so  that  few  cases  have  been  reported  there 
during  the  past  two  summers." 

There  is,  perhaps,  at  the  present  time  no  more  fruitful  field  of  special- 
ized inquiry  into  the  occurrence  of  malarial  disease  in  the  North  than 
the  State  of  Connecticut.  A  large  amount  of  exceptionally  valuable 
new  material  is  available  to  continue  the  "Observations  on  the 
Etiology  of  the  Malarial  Diseases  at  Present  Prevalent  in  South- 
western New  England,"  by  Rufus  W.  Griswold,  M.  D.,  of  Rocky 
Hill,  Connecticut,  1886.  All  the  evidence  derived  from  official  and  other 
sources  sustains  the  conclusion  that  malaria  as  a  disease  and  as  a  com- 
plicating factor  in  other  diseases  is  much  more  common  in  New  England 
at  the  present  time  than  is  generally  assumed  to  be  the  fact. 


77 


PART  II 

MALARIA  IN  RELATION  TO  WAR 

MALARIA  IN  THE  CIVAL  WAR 

For  a  hundred  years,  at  least,  the  mihtary  importance  of  malaria  has 
been  clearly  recognized  by  army  authorities.  During  our  Civil  War, 
largely  on  account  of  the  fact  that  the  military  activitie.s  were  practi- 
cally confined  to  the  Southern  States,  malaria  became  wide-spread 
among  the  troops,  and,  according  to  Prinzing's  treatise  on  Epidemics 
Resulting  from  Wars,*  "on  an  average,  no  less  than  fifty-two  per  cent, 
of  the  white  troops  and  eighty-three  per  cent,  of  the  colored  troops  con- 
tracted the  disease  per  annum."  Much  valuable  information  on  the 
subject  is  contained  in  the  "Medical  and  Surgical  History  of  the  War," 
which  is  chiefly  relied  upon  by  Prinzing,  who  properly  directs  attention 
to  the  fact  that  the  negro  troops  were  by  no  means  immune  to  the 
disease,  but,  quite  to  the  contrary,  contracted  it  much  more  frequently 
and  suffered  a  great  deal  more  severely  from  it  than  the  whites.  Grant- 
ing the  inherent  defects  of  all  military  medical  statistics,  with  reference 
to  which  the  original  information  is  frequently  secured  with  exceptional 
difficulty,  our  Civil  War  data  are  nevertheless  of  much  interest  and 
practical  value  at  the  present  time,  f  A  convenient  summary  account 
of  the  prevalence  of  malaria  among  the  Northern  troops,  both  white 
and  colored,  is  presented  by  Prinzing  in  the  table  following  :J 

MORBIDITY  AND  MORTALITY  FROM  MALARIA  DURING 

THE  CIVIL  WAR 

(Rate  per  1,000  Exposed  to  Risk) 

WHITE  TROOPS 
No.  Patients 

1861-1862 404.0 

1862-1863 460.1 

1863-1864 584.1 

1864-1865 558.4 

1865-1866 853.1 

•"Epidemics  Resulting  from  Wars,"  by  Dr.  Friedrich  Prinzing,  edited  by  Harald  Westergaard,  published 
by  the  Carnegie  Endowment  for  International  Peace,  Oxford,  1916. 

tThe  full  title  of  this  invaluable  source  of  useful  medical  and  statistical  information  is  "Medical  and  Surgical 
History  of  the  War  of  the  Rebellion,"  Washington,  1888. 

^"Epidemics  Resulting  from  Wars,"  page  180. 

79 


s 

COLORED  TROOPS 

B.  Deaths 

No.  Patients 

No.  Deaths 

2.77 

.  . 

.  . 

3.76 

.  . 

,  , 

3.19 

833.7 

15.19 

3.34 

750.0 

8.77 

5.42 

947.0 

7.81 

The  total  number  of  deaths  from  malaria  among  the  white  troops 
during  the  Civil  War,  with  an  average  strength  of  468,000  per  annum 
for  the  white  troops,  was  8,140,  or  17.4  per  1,000;  while  for  the  colored 
troops,  with  an  average  strength  of  63,645  per  annum,  limited,  however, 
to  1863-1866,  the  total  number  of  deaths  from  malaria  was  1,923,  or 
30.1  per  1,000  per  annum. 

MALARIA  IN  PRISON  CAMPS 

In  Northern  and  Southern  prisons  the  mortality  from  malaria  was 
much  less  than  expected,  due,  no  doubt,  to  the  extraordinary  mor- 
tality from  other  causes.  According  to  Prinzing,  the  annual  rate  per 
1,000  from  all  causes  among  Confederate  prisoners  in  Northern  prisons 
was  230.7,  of  which  the  mortality  from  malaria  was  12.6,  and  from 
typhoid  and  typhus  fever,  13.6.  In  contrast,  the  mortality  from 
diarrhea  and  dysentery,  combined,  was  73.0,  and  from  inflammation 
of  the  lungs  and  pleurisy,  61.7. 

In  Southern  prisons  the  conditions  were  still  worse.  Apparently  in 
Anderson ville  alone  the  annual  mortality  was  792.8  per  1,000,  of  which 
the  mortality  from  malaria  was  only  12.2,  and  from  typhoid  and  typhus 
fevers,  20.5.  In  contrast,  the  mortality  from  diarrhea  and  dysentery, 
combined,  was  465.6,  and  from  inflammation  of  the  lungs  and  pleurisy, 
27.4.* 

In  Northern  prisons  the  mortality  from  scurvy  was  4.3  per  1,000, 
against  a  rate  of  102.8  in  Southern  prisons.  Such  an  extraordinary 
mortality  from  more  immediately  fatal  diseases  would  naturally  tend 
strongly  to  reduce  the  mortality  from  malaria,  although  in  all  proba- 
bility malaria  was  a  complicating  factor  in  a  large  number  and  propor- 
tion of  deaths  due  to  other  diseases. 

METHODS  OF  QUININE  PROPHYLAXIS 

The  possibilities  of  malaria  prevention  and  control  were  recognized 
by  the  Army  authorities  of  the  day,  but  the  difiiculties  to  be  overcome 
were  enormous,  f  The  true  nature  of  malaria  as  a  disease  transmissible 
through  the  mosquito  not  being  understood  at  the  time,  chief  reliance  was 
placed  upon  quinine  prophylaxis.     In  amplification  of  suggestions  with 

*The  annual  mortality  rate  for  Andersonville  prison  is  based  upon  the  six  months'  experience  March  1  to 
August  31,  1864,  when  of  an  average  number  of  19,453  prisoners  7,712,  or  39.6  per  cent.,  died,  equivalent 
to  an  annual  rate  of  792.8  per  1,000.     (See  Prinzing,  loco  citato,  p.  181.) 

tSee  Report  P  of  the  Sanitary  Commission  on  the  Nature  and  Treatment  of  Miasmatic  Fevers,  Washington, 
1862, 

80 


reference  to  the  use  of  quinine  contained  in  the  "Rules  for  Preserving 
the  Health  of  the  Soldiers,"  issued  under  date  of  July  13,  1861,  the 
Sanitary  Commission  issued  a  special  report  of  a  committee  appointed 
to  prepare  a  paper  on  the  use  of  quinine  as  early  as  1862.  This  publica- 
tion, though  rarely  referred  to  in  the  literature  of  the  subject,  was  a  most 
important  document,  which  deserves  to  be  much  better  known  than  is 
actually  the  case.  The  report  concludes  with  words  which  may  well  be 
taken  to  heart  at  the  present  time,  that  "viewed  in  the  light  of  humanity 
as  well  as  of  economy — both  of  men  and  money — the  prevention  of 
disease  is  of  far  greater  importance  than  its  cure,  and  your  Committee 
venture  to  express  the  opinion  that  intelligent  and  judicious  action  on 
this  important  subject  at  the  hands  of  the  authorities  would  save  much 
sickness  and  many  valuable  lives  during  the  present  campaign."* 

MALARIA  IN  THE  EUROPEAN  WAR  AREA 

It  requires  no  argument,  of  course,  to  prove  that  the  importance  of 
malaria  in  relation  to  war  is  more  clearly  recognized  by  modern 
military  authorities.  In  a  treatise  on  "Military  Hygiene  and  San- 
itation," Lieutenant-Colonel  Frank  R.  Keefer,  of  the  United  States 
Medical  Corps,  quotes  Major-General  Gorgas  as  having  given  expres- 
sion to  the  opinion  that  "when  troops  are  marching  through 
a  malarious  country  the  only  practical  measures  for  their  protection 
the  administration  of  quinine."  He  adds,  however,  and  wisely  so,  that 
"if  a  camp  is  occupied  for  more  than  a  day  or  two  the  ground  should, 
of  course,  be  cleared  and  accumulations  of  water  drained  away  or  oiled." 

*It  is  properly  pointed  out  in  an  editorial  in  The  Lancet  (February  23,  1918)  on  Quinine  in  the  Treatment 
and  Prevention  of  Malaria  that  "At  no  time  has  it  been  more  important  than  now  to  understand  the  exact 
method  of  administration  of  quinine  by  which  the  malaria  parasite  may  best  be  attacked,  no  matter  whether 
our  knowledge  is  obtained  by  comparison  of  the  practical  experience  gained  empiricallj'  from  treating  patients 
or  is  to  be  inferred  from  the  results  of  special  research."  In  recognition  of  the  practical  importance  of  this 
question  the  British  War  Office  early  in  1917  arranged  for  a  concentration  of  malaria  cases  returned  from 
overseas  in  special  hospitals  in  England  for  treatment  by  specially  qualified  medical  officers  who  were  invited  to 
cooperate  in  a  scheme  for  comparison  of  the  practical  results  obtained  from  different  lines  of  treatment.  The 
reports  which  have  been  made  have  recently  been  summarized  by  Sir  Ronald  Ross,  the  adviser  of  the  War 
Office,  in  an  article  contributed  to  the  Proceedings  of  the  Society  of  Tropical  Medicine.  According  to  the 
editorial  in  The  Lancet,  "The  result  from  all  the  quinine  treatments  taken  together  was  represented  by  some 
27  per  cent,  of  ascertained  relapsing  cases  in  a  total  of  about  2,500  patients.  At  Oxford  a  control  was  afforded 
by  192  men  who  were  watched  without  any  quinine  treatment  at  all,  and  of  these  89  relapsed  within  27  days, 
and  76  were  presently  judged  not  to  be  sufficiently  well  to  allow  of  quinine  treatment  being  withheld  any 
longer;  so  that  86  per  cent,  of  the  untreated  cases  remained  ill  and  46.5  per  cent,  actually  suffered  from  relapses 
during  the  period." 

Of  exceptional  value  is  the  conclusion  that  "The  evidence  that  continued  daily  doses  of  only  five  grains 
afford  a  relatively  slight  protection  against  relapse  is  important,  and  no  doubt  accounts  for  much  of  the  dis- 
appointment which  has  been  expressed  at  the  results  of  the  prophylactic  use  of  quinine  in  this  dosage  in  the 
malarious  areas  of  Macedonia,  where  relapses  are  so  common  among  the  large  proportion  of  the  force  which  has 
become  infected."  Equally  suggestive  is  the  further  conclusion  that  "If  the  view  is  now  to  prevail  that  the 
failure  of  the  prophylactic  use  of  quinine  under  war  conditions  has  been  demonstrated,  we  hope  that  the  causes 
of  the  failure  and  the  nature  of  the  proof  will  be  fully  analysed  and  discussed." 

81 


The  malaria  problem  in  its  military  aspects  is,  however,  much  more 
complex  than  is  indicated  by  this  brief  reference  to  the  subject  in  the 
text-book  referred  to. 

In  a  recent  treatise  on  "Sanitation  in  War,"  by  Major  P.  S.  Lelean, 
more  extended  consideration  is  given  to  the  role  of  insects  in  war,  with 
especial  reference  to  mosquitoes,  attention  being  directed  to  the  fact 
that  in  western  Europe  the  usual  malaria-carrying  mosquito  is  the 
species  known  as  Anopheles  maculipennis;  in  southern  Europe  the 
chief  malaria-carriers  are  A.  maculipennis  and  A.  superpictus;  in  Egypt 
the  principal  disseminator  is  A.  {Cellia)  pharoensis.  Since  in  most  cases 
the  services  of  a  trained  entomologist  are  required  to  differentiate  the 
different  species,  or  those  that  are  known  to  be  harmless  from  those  that 
are  not,  Lelean  suggests  that  "the  only  safe  rule  of  conduct  for  the 
sanitary  officer  is  to  regard  all  mosquitoes,  and  especially  all  species  of 
anopheles,  as  potentially  dangerous,  and  immediately  to  search  for 
and  take  the  necessary  steps  to  destroy  the  breeding  places  whenever 
mosquitoes  resting  in  the  characteristic  Anopheline  attitude,  or  the 
equally  characteristic  larvae  are  found."  An  additional  recommenda- 
tion is  to  the  effect  that  "whenever  possible,  mosquito  breeding-places 
should  be  destroyed  by  filling  them  in  with  earth  or  sand.  Stagnant 
pools  to  which  this  treatment  cannot  be  applied  should  be  rendered 
harmless  by  oiling  the  surface,  at  least  once  a  week,  with  a  mixture  of 
equal  parts  of  green  oil  and  petroleum,  at  the  rate  of  half  an  ounce  to 
the  square  yard."  Aside  from  the  foregoing,  Lelean  suggests  the  en- 
forcement of  all  the  well-known  methods  and  precautions  primarily 
directed  against  the  extermination  of  the  mosquito,  rather  than  the 
immunizing  of  malaria-carriers. 

MALARIA  AND  "TRENCH  FEVERS" 

The  extent  to  which  malaria  has  been  a  factor  of  military  importance 
on  the  western  front  is  not  yet  a  matter  of  sufficient  information  to 
justify  alarming  conclusions.  In  a  report  by  Surgeon  A.  M.  Faunt- 
leroy  on  the  Medico-Military  Aspects  of  the  European  War  issued  in 
1915,  the  statement  is  made  that  "Except  for  an  occasional  recurrent 
attack  of  malaria  in  individuals  who  formerly  contracted  the  disease 
while  living  in  the  south,  there  is  no  evidence  of  any  ill  effects  from  the 
presence  of  the  few  mosquitoes  at  the  front."  There  are,  however, 
reasons  for  believing  that  this  statement  is  no  longer  in  conformity  to 
the  facts,  if,  indeed,  it  was  strictly  accurate  even  at  the  time  when  the 


observations  were  made.  For,  as  observed  in  a  treatise  on  "The 
Medical  Diseases  of  the  War,"  by  Arthur  F.  Hurst,  "The  possibiHty  of 
malaria  must  always  be  considered,  and  a  blood  film  should  be  examined 
for  the  malarial  plasmodium  before  making  a  definite  diagnosis  in  cases 
of  doubt,  especially  if  the  patient  has  previously  had  malaria,  or  when  it 
is  prevalent,  as  was  the  case  during  the  summer  in  Salonica."  The 
term  "trench  fever,"  which  has  become  generally  accepted,  represents, 
probably,  a  group  of  diseases  in  which  the  diagnosis  is  often  doubtful. 
How  much  of  the  so-called  "trench  fever,"  if  any,  is  true  malaria 
originally  contracted  on  the  western  front  or  recurrent  malaria  among 
troops  exposed  to  infection  in  more  intensely  malarial  areas  cannot 
at  the  present  time  be  decided.  Hurst  calls  attention  to  the  fact 
that  "The  aestivo-autumnal  form  of  malaria  may  closely  resemble 
paratyphoid  fever";  that  "the  differentiation  can  then  only  be  made 
by  a  blood  examination,  as  remissions  may  be  slight,  and  typical 
rigors,  though  not  uncommon  in  paratyphoid  fever,  do  not  always  occur 
in  malaria." 

In  an  admirable  treatise  on  "Military  Hygiene,"  Havard  properly 
points  out  that  "Malarial  fever,  intermittent  fever,  ague,  chills  and 
fever,  are  different  names  for  the  same  disease."  In  his  observations 
on  prophylaxis  he  directs  attention  to  (1)  the  destruction  of  mosquitoes, 
(2)  protection  against  mosquito  bites,  (3)  the  isolation  and  protection 
of  malarial  patients  and  (4)  medical  prophylaxis,  chiefly  quininization. 
Mason,  in  a  "Hand  Book  for  the  Sanitary  Troops,"  also  concludes 
that  in  malaria  "the  sick  must  be  protected  against  mosquitoes,  so  that 
the  mosquitoes  cannot  get  the  disease,  and  the  well  must  also  be  pro- 
tected so  that  if  there  are  any  infected  mosquitoes  about  they  may  not 
do  any  harm."* 

The  application  of  these  observations  to  the  European  War  and  the 
solution  of  sanitary  problems  in  this  country  in  connection  with  military 
activities  is  self-evident.  The  risk  of  a  wide-spread  malarial  recurrence 
in  regions  heretofore  practically  free  therefrom  is  unquestionably  much 
more  serious  than  generally  assumed,  f 

•The  principal  modern  works  of  reference  on  military  hygiene  are:  "Manual  of  Military  Hygiene,"  by 
Valery  Havard,  M.  D.,  New  York,  1914,  "A  Complete  Handbook  for  the  Sanitary  Troops  of  the  U.  S.  Army 
and  Navy,"  by  Charles  Field  Mason,  New  York,  1917,  "A  Text-Book  of  Military  Hygiene  and  Sanitation,"  by 
Frank  R.  Keefer,  M.  D.,  Philadelphia,  1917,  "Sanitation  in  War,"  by  Major  P.  S.  Lelean,  London,  1917. 

fThe  effects  of  malaria  on  wounds  have  been  discussed  by  Vandenbosche  in  a  thesis  presented  to  the  Uni- 
versity of  Lyons  (abstracted  in  the  Joum.  de  med.  et  de  ehir.  prat.,  April  25,  1917),  based  upon  his  observations 
at  Salonica.  Of  special  importance  is  the  conclusion  that:  "Unless  the  possibility  of  malaria  be  borne  in  mind, 
fever  in  a  wounded  man  may  mislead  the  most  experienced  surgeon  into  enlarging  the  wound."  Vanden- 
bosche further  calls  attention  to  malaria  gangrene  as  fortunately  rare;  but  he  also  mentions  "cases  in  which  a 
malaria  attack  simulating  appendicitis  has  brought  the  patient  to  the  operating  table." 

83 


MALARIA  IN  THE  WESTERN  WAR  AREA 

Etienne,  a  French  surgeon,  in  a  discussion  of  the  subject  has  directed 
attention  to  the  revival  of  the  ancient  form  of  endemic  malaria  in  the 
Seille  Valley,  which  has  always  been  infested  with  the  malarial  mosquito, 
but  in  which  no  new  cases  had  occurred  since  1888  until  subsequently  to 
the  outbreak  of  the  war.  Cases  first  met  with  in  1915  were  all  in  persons 
who  ha^d  never  been  in  tropical  or  other  malarial  regions.  Etienne  is  of 
the  opinion  that  "troops  from  Africa  and  French  China  have  brought 
virulent  malaria  parasites  into  the  country,  and  thus  the  mosquitoes  are 
serving  anew  as  intermediary  hosts."  In  a  letter  contributed  to  the 
Le  Bulletin  Medical,  Paris,  of  August  12,  1916,  considerable  new  in- 
formation is  made  public  regarding  the  forms  of  malaria  in  the  sphere 
of  warfare  at  and  in  the  vicinity  of  Salonica.  The  opinion  is  advanced 
that  soldiers  coming  from  France  have  become  contaminated  on  their 
arrival,  the  positive  diagnosis  having  been  made  in  the  bacteriological 
laboratories  of  the  Eastern  Army.  A  study  of  the  blood  shows  the  three 
principal  forms  of  the  malarial  parasite.  Since  the  primary  form  of 
malaria  is  not  met  with  in  France  under  normal  conditions,  the  onset  of 
the  disease  is  generally  not  recognized  by  the  patient,  who  "is  greatly 
prejudiced  because  he  does  not  receive  his  quinine  at  the  outset."  In 
the  experience  of  the  Eastern  Army  the  attacks  of  primary  malaria  are 
followed  at  an  early  date  by  a  series  of  daily  intermittent  attacks,  even 
in  the  absence  of  a  reinfection.  In  the  absence  of  proper  treatment 
"anemia  appears,  followed  by  enlargement  of  the  spleen,  and  may  pass 
on  to  a  true  cachexia  with  anasarca  or  simple  edema  of  the  legs  and  face, 
oliguria,  palpitation,  anorexia,  diarrhea,  apathy  and  torpor."  Other 
complications  have  been  observed  in  the  experience  of  the  French  army, 
one  case  of  anterior  spinal  general  paralysis  in  a  soldier  having  been 
reported  as  due  to  a  malarial  infection  originally  contracted  by  an  officer 
who  had  left  Bordeaux  for  Africa  and  developed  malaria  during  a  stay 
of  eighteen  days  in  the  tropics. 

MALARIA  IN  THE  EASTERN  WAR  AREA 

In  appreciation  of  the  seriousness  of  the  situation  in  the  Eastern  Army 
the  soldiers  at  and  in  the  vicinity  of  Salonica  are  required  to  take  daily 
five-grain  doses  of  quinine  as  a  preventive  measure,  in  conformity,  no 
doubt,  to  the  point  of  view  previously  referred  to,  as  having  been  given 
expression  to  by  Major-General  Gorgas,  on  the  basis  of  his  experience 
in  Cuba  and  at  Panama.  This  procedure  has  been  severely  criticized 
by  E.  Halford  Ross,  one  of  the  foremost  authorities  on  malaria  eradica- 

84 


tion,  who  is  of  the  opinion  that  quininization  cannot  possibly  prove 
effective,  or,  in  his  own  words,  "It  is  almost  heart-breaking  for  those  of 
us  who,  having  broiled  for  years  in  hot  climates  dealing  successfully 
with  disease,  find  now,  after  two  decades  of  hard-gained  knowledge, 
military  authorities  reverting  to  methods  which  are  not  only  out  of  date 
and  hard  to  carry  out  completely,  but  are  also  very  costly."  He  holds 
that  five  grains  of  quinine  is  an  item  of  considerable  expense  and  that 
such  methods  of  procedure  are  unnecessary  if  proper  antimosquito 
measures  are  carried  rigorously  into  effect. 

In  contrast  to  this  point  of  view,  evidence  has  been  brought  forward 
that  in  the  Italian  army  the  amount  of  malaria  was  reduced  from  fifty 
to  five  per  1,000  during  a  single  decade,  in  response  to  systematic 
quinine  prophylaxis.  This  experience,  however,  was  previous  to  the 
war,  when  the  difficulties  of  complete  sanitary  control  have  become 
enormous.  According  to  a  brief  note  in  the  London  Lancet,  of  Decem- 
ber 30,  1916,  "Malaria,  the  most  important  of  all  tropical  diseases,  has 
been  making  its  presence  felt  in  some  of  the  war-zones,  causing  mor- 
tality and  invalidity  among  our  expeditionary  forces,  particularly 
among  the  troops,  both  French  and  English,  operating  in  the  Valley  of 
the  Vardar,  north  of  Salonica.  In  this  unhealthy  region  many  soldiers 
contracted  malaria  in  spite  of  a  daily  prophylactic  dose  of  five  grains  of 
quinine."  Reference  is  then  made  to  a  discussion  of  the  value  of 
quinine  prophylaxis  at  a  meeting  of  the  Society  of  Tropical  Medicine 
and  Hygiene,  at  which  Dr.  Angus  Macdonald,  of  Kingston,  Jamaica, 
read  a  paper  on  the  Position  of  Malaria  in  Sanitary  Administration. 
It  is  said  that  in  this  address  "He  maintained  that  continuous  drugging 
with  quinine  might  prevent  attacks  of  malaria  in  anopheline  countries, 
but  statistics  were  still  lacking  to  demonstrate  the  extent  to  which  the 
use  of  this  drug  prevents  the  occurrence  of  the  disease."  This  view- 
point was  endorsed  by  Surgeon-General  Sir  David  Bruce,  who  also 
expressed,  from  personal  experience,  some  skepticism  in  regard  to 
quinine  as  a  prophylactic  against  malaria,  adding  that  he  wished  that 
the  matter  could  be  "settled  once  for  all  by  good  evidence."* 

*0f  special  value  for  this  purpose  should  be  the  quinine  immunization  or  prophylactic  disinfection  demon- 
stration carried  on  by  the  International  Health  Board  in  Bolivar  County,  Mississippi,  under  the  direction 
of  Dr.  C.  C.  Bass ,  of  New  Orleans.     See  page  28,  et  seq. 

According  to  N.  Samaja,  in  a  contribution  to  the  Gazzetta  degli  Ospedali  e  delle  Cliniche,  Milan,  January, 
1918,  "Malaria  is  the  one  disease  encountered  most  frequently  now  in  the  Italian  military  hospitals.  Among 
417  patients  in  his  service  at  Bologna,  244  had  malaria.  Among  the  symptoms  of  intolerance  of  quinine, 
occasionally  noted,  hemorrhagic  purpura  was  not  exceptional,  but  the  dose  of  quinine  usually  was  large  when 
this  by-effect  was  observed.  The  attacks  of  hemorrhagic  purpura  followed  whether  the  quinine  was  given  by 
the  mouth  or  subcutaneously,  and  in  constantly  smaller  doses  down  to  0.10  grams,  but  the  intensity  of  the 
purpura  was  less  pronounced  with  the  smaller  doses." 

85 


MALARIA  RECURRENCE  IN  BELGIUM  AND  NORTHERN 

FRANCE 

With  more  specific  reference  to  the  western  front,  Renaux  in  an  article 
contributed  to  the  "Medical  Archives  of  Belgium,"  Paris,  January, 
1917,  remarks  that  "although  acute  malaria  has  long  had  only  historical 
interest  in  Belgium,  yet  malaria  has  never  died  out  completely  there. 
A  few  chronic  cases  have  been  encountered  from  time  to  time  in  the  last 
few  decades.  But  the  wartime  conditions,  the  flooding  of  the  country 
as  a  protection  against  the  enemy,  and  defective  hygienic  measures  have 
led  to  the  flaring  up  anew  of  the  old  embers  of  malaria,  and  he  had  been 
able  to  identify  nineteen  cases  in  the  Bourbourg  and  Gravelines  hos- 
pitals. Malaria  had  not  been  suspected  at  first,  and  the  cases  had  been 
labeled  pneumonia,  grip,  febrile  gastric  disturbance,  etc.  None  of 
these  affected  had  ever  been  in  tropical  countries.  The  lack  of  any 
regularity  in  the  recurrence  of  the  fever  aided  in  the  overlooking  of  the 
true  cause  of  the  disturbances.  Even  when  there  was  a  regular  rhythm 
in  the  fever,  it  varied  from  daily  to  tertian,  and  vice  versa.  Under 
quinine  the  men  rapidly  recovered,  and  only  two  returned  with  a  recur- 
rence. The  parasites  were  of  different  sizes  and  seemed  to  represent  a 
type  midway  between  the  quartan  and  the  benign  tertian.  He  noted 
in  the  blood  of  these  patients  numerous  basophil  punctuated  red  cor- 
puscles, such  as  are  considered  typical  of  anemia  and  lead  poisoning." 

CLINICAL  ASPECTS  OF  MALARIA  CONTROL 

Drs.  Falconer  and  Anderson,  in  a  communication  to  The  Lancet,  of 
April  21,  1917,  on  "Clinical  Types  of  Subtertian  Malaria  as  Seen  in 
Salonika  in  September,  October  and  November,  1916,"  including  over 
3,600  cases,  stated  that  the  majority  of  these  cases  "were  of  the  simplest 
subtertian,  double  subtertian  and  irregular  types  of  subtertian  pyrexia, 
without  local  manifestations.  These  cases  uniformly  responded  well 
to  treatment  with  quinine.  The  most  important  group  of  cases  with 
local  symptoms,  on  account  both  of  relative  frequency  and  of  difficulty 
of  differential,  were  characterized  by  more  or  less  urgent  gastrointestinal 
symptoms.  This  group  could  be  separated  into  several  more  or  less 
definite  types:  Dysenteric,  in  which  the  stools,  from  six  to  fifteen  in 
twenty-four  hours,  were  fluid  and  feculent,  without  definite  blood  and 
mucus,  while  in  a  smaller  number  of  cases  the  stools  contained  definite 
blood  and  mucus.  It  was  possible  in  the  great  majority  of  these  cases 
to  demonstrate  a  superadded  infection  with  one  of  the  organisms  of  the 

86 


dysenteric  group.  Choleraic  pernicious  fever,  of  which  but  two  cases 
were  met  with,  and  both  cases  died  within  fifteen  hours  on  admission  in 
spite  of  intravenous  quinine  and  salines.  Appendicular  types,  in  which 
the  cases  strongly  resembled  appendicitis.  There  were  twelve  cases  in 
this  group,  and  the  chief  complaint  was  vomiting,  and  severe  pain  referred 
to  the  right  iliac  fossa,  associated  with  moderate  pyrexia  and  marked  ten- 
derness and  rigidity  in  the  same  fossa.  In  most  of  the  cases  the  rigidity 
was  not  constant.  Leucocytosis  was  absent,  but  the  typical  relative  lym- 
phocytosis of  malaria  was  present.  All  rapidly  cleared  up  under 
quinine.  Bilious  remittent  fever,  from  which  thirteen  of  their  fatal 
cases  succumbed.  Jaundice,  with  vomiting,  bilious  diarrhea,  and 
mental  confusion  were  chief  symptoms.  After  quinine  intravenously, 
they  apparently  improved,  only  to  later  succumb  and  die  in  coma  or 
delirium.  Pernicious  fever  with  pulmonary  symptoms,  in  which 
both  numerically  and  as  a  cause  of  death,  this  was  the  next  most  im- 
portant group,  in  which  the  patients'  dominant  symptoms  were 
referred  to  the  respiratory  tract.  Of  the  cases  of  malaria  which  ter- 
minated fatally,  pulmonary  complications  of  a  pneumonic  or  broncho- 
pneumonic  character  were  present  in  seven,  and  were  the  immediate 
cause  of  the  fatal  issue.  Among  others  were  the  bronchitic  type, 
the  pneumonic  and  bronchopneumonic  type,  including  the  deaths  above 
mentioned,  and  in  which  the  subtertian  parasites  were  demonstrated 
in  the  blood.  Cerebral  cases,  which  formed  a  small  but  interesting 
group.  There  were  nine  cases  of  this  type,  due  to  local  affections  of  the 
nervous  system.  Generalized  edema  with  ascites,  two  cases.  Gangrene 
of  the  feet  comprised  another  group,  consisting  of  three  cases  which 
showed  evidence  of  gangrene  of  the  toes.  In  all,  thirty  cases  infected 
with  malaria  died,  and  with  the  exclusion  of  thirteen  cases  dying  from 
complications,  seventeen  cases  succumbed  to  uncomplicated  malaria." 

URGENCY  OF  DRASTIC  PREVENTIVE  MEASURES 

It  has  seemed  appropriate  to  quote  the  foregoing  observations  in 
exienso,  on  account  of  the  large  number  of  cases  under  observation  and 
the  thoroughly  qualified  scientific  analysis  of  the  facts.  The  experience 
proved  conclusively  the  practical  importance  of  the  question  from  a 
military  point  of  view  and  the  imperative  duty  of  the  adoption  of 
effective  precautionary  measures,  aside,  of  course,  from  the  necessary 
provision  for  the  verification  of  the  clinical  diagnosis  by  the  micro- 
scopical examination  of  the  blood  smears,  etc.  Errors  of  treatment  are  as 

87 


likely  to  prove  of  serious  consequence  as  indifference  to  the  adoption  of 
precautionary  measures,  with  or  without  reference  to  quinine  prophy- 
laxis. Captain  H.  Stott,  of  the  India  Medical  Service,  in  a  treatise  on 
"Studies  in  Malaria,"  has  included  an  interesting  account  of  his  ex- 
perience of  hyperpyrexial  heat-stroke  in  Mesopotamia  during  1915, 
which  justified  the  conclusion  that  "in  many  cases  it  was  evidence  of  a 
malarial  infection,"  while  in  some  others  "it  was  connected  with  the 
enteric  gioup  of  fevers."  He  adds,  however,  that  the  heat  from  the 
Persian  Gulf  during  June,  1915,  was  intense,  and  the  relative  humidity 
of  the  atmosphere  very  high.  Out  of  thirty-three  European  patients 
with  heat-stroke,  it  was  found  that  thirteen  had  an  active  concomitant 
malarial  infection,  and  that  in  five  more  the  presumptive  evidence  in 
favor  of  malaria  was  very  strong.  Captain  Stott  explains  that  "Usually 
the  patient  was  struck  down  suddenly  with  a  well-marked  heat-stroke 
of  107  or  108  degrees  Fahrenheit,  and  malarial  parasites  were  subse- 
quently found  in  the  blood;  no  doubt  definite  cerebral  malaria  was 
present  in  some  cases.  Seven  others  of  the  thirty-three  patients  gave  a 
positive  Widal  reaction  that  was  sufficiently  strong  to  be  taken  as 
evidence  of  an  enteric  group  infection;  typical  typhoid  ulceration  in  the 
jejunum  and  upper  ileum  was  found  in  one  case  with  a  fatal  ending. 
Two  of  the  seven  also  had  an  active  malarial  infection.  In  eight  only 
of  the  thirty-three  cases  of  heat-stroke  was  there  no  clear  evidence  of 
any  concomitant  infective  process." 

PRACTICAL  MILITARY  ASPECTS  OF  MALARIA  CONTROL 

These  varied  aspects  of  the  malaria  problem  are  but  a  fragmentary 
indication  of  the  extreme  complexity  of  its  relation  to  military  opera- 
tions and  the  changed  civil  conditions  subsequent  to  the  reestablishment 
of  peace.  The  experience  which  was  had  during  our  war  with  Spain, 
when  malaria  was  reintroduced  into  certain  sections  of  Connecticut  by 
the  troops  returning  from  thoroughly  infected  areas  in  Cuba  and  Porto 
Rico,  requires  to  be  kept  constantly  in  mind,  if  even  more  lamentable 
results  are  to  be  avoided  at  the  present  time.  As  observed  by  E.  Hal- 
ford  Ross,  the  experience  of  the  past  is  unhappily  only  too  often  set 
aside  out  of  consideration  of  matters  of  temporary  expediency.  With 
commendable  foresight,  however,  the  Government  of  Australia  has  set 
an  example  of  protective  measures  which  may  well  receive  consideration 
in  this  country  at  the  present  time.     In  behalf  of  the  Quarantine  Service 

•For  a  more  extended  discussion  of  the  climatological  aspects  of  malaria,  especially  with  reference  to  atmos- 
pheric conditions,  see  "A  Plea  and  a  Plan  for  the  Eradication  of  Malaria,"  pp.  42  and  58,  et  seq. 

88 


of  the  Commonwealth  of  AustraHa,  Mr.  F.  H.  Taylor,  Entomologist 
of  the  Australian  Institute  of  Tropical  Medicine,  has  prepared  a 
Malaria  Mosquito  Survey  of  Irrigation  Areas  in  the  Murray  River 
District,  where  preparations  were  being  made  to  establish  the  Aus- 
tralian soldiers  for  agriculture  and  other  purposes.  As  observed  in  the 
introduction  to  the  report,  by  Dr.  J.  H.  L.  Cumpston,  Director  of 
Quarantine,  "Owing  to  the  return  from  military  service  abroad  in  New 
Guinea,  Egypt,  etc.,  of  many  men  infected  with  malaria,  it  was  con- 
sidered to  be  a  matter  of  fundamental  importance  that  irrigation  dis- 
tricts, where  preparations  were  being  made  to  establish  many  returned 
men,  should  be  examined  in  order  that  the  absence  or  prevalence  of 
the  malaria  carrying  species  of  mosquito  should  be  determined.  This 
decision  was  arrived  at  during  a  conference  upon  the  question  of  malaria 
convened  by  Surgeon-General  Fetherston,  Director-General  of  Army 
Medical  Services  in  Australia."  The  survey  was  made  regardless  of 
many  practical  diflSculties,  and  the  principal  centers  in  the  irrigation 
districts  were  examined  and  reported  upon  in  sufficient  detail  for  the 
end  in  view.  It  was  ascertained  without  the  chance  of  serious  error 
that  the  malarial  mosquito  was  to  be  found  right  through  the  irrigation 
area,  with,  possibly,  two  exceptions.  It  is  said  by  Dr.  Cumpston  that 
not  only  was  this  so,  but  that  "they  were  chiefly  to  be  found  close  to 
human  habitations,  indicating  that  an  increase  in  the  human  blood- 
supply  available  would  probably  be  followed  by  an  increase  in  the 
numbers  of  these  species."  The  far-reaching  conclusion  was  therefore 
advanced  that  "It  is  obvious  that  no  man  should  be  allowed  to  settle 
in  these  areas  whose  record  shows  that  he  has  suffered  while  on  service 
from  malaria,  or  in  whose  blood  the  malarial  parasites  are  found"; 
and,  furthermore,  that  "Moreover,  every  endeavor  should  be  made  to 
create  such  conditions  in  these  areas  that  malaria-carrying  mosquitoes 
will  not  breed,  as  the  casual  introduction  of  infection  may  be  productive 
of  a  serious  outbreak  of  malaria."* 

The  risk  of  malaria  in  the  summer  and  autumn  campaign  of  1915  was 
made  the  subject  of  an  extended  editorial  discussion  in  The  British 
Medical  Journal,  of  July  24th  of  that  year.  After  observing  that  the 
suggestion  had  been  made,  "and  not  without  good  reason,"  that  there 
was  a  danger  of  malaria  becoming  prevalent  in  Flanders  that  autumn, 
it  is  said  that  though  the  disease  had  practically  disappeared  from 

•According  to  the  Journal  of  the  American  Medical  Association,  March  23,  1918,  the  City  Council  of  Phila- 
delphia has  been  requested  by  the  Director  of  Public  Works  to  appropriate  an  additional  $20,000  for  a  cam- 
paign to  exterminate  mosquitoes  in  the  vicinity  of  the  League  Island  Navy  Yard  and  the  Hog  Island  ship 
building  plant,  supplementary  to  an  appropriation  of  $10,000  previously  made. 

89 


England,  it  still  occurred  in  Holland,  and  that  there  were  no  good 
reasons,  given  the  proper  conditions,  why  the  disease  should  not  appear 
in  Flanders  that  year.  To  appreciate  the  extent  of  the  danger  certain 
conditions  are  emphasized,  as  follows:  "In  the  first  place,  a  malaria- 
carrying  mosquito  must  be  present;  in  the  second,  human  beings 
carrying  gametocytes  (that  is,  the  sexual  form  of  the  malarial  parasite) 
in  their  blood  must  be  there  to  infect  the  mosquito;  and  in  the  third 
place,  a  suitable  temperature  must  exist  in  order  that  the  development 
of  the  parasite  may  take  place  in  the  insect  host."  As  regards  the  first, 
the  article  points  out  that  the  Anopheles  maculipennis,  which  is  the 
chief  malaria-carrier  of  Italy,  Greece  and  the  southern  parts  of  Europe, 
"is  present  not  only  in  Flanders  and  France,  but,  as  a  matter  of  fact,  in 
England  itself."*  As  regards  malaria-carriers,  or,  in  other  words, 
persons  harboring  gametocytes  in  their  blood,  it  is  suggested  that  they 
are  probably  present,  "because  Indian  troops  are  employed  in  Flanders 
at  the  present  moment,  and  such  being  the  case,  the  question  arises 
whether  malaria  may  be  expected  to  break  out."  Practically,  however, 
it  is  held  this  would  depend  entirely  on  the  weather,  and  if  the  season 
should  prove  sufficiently  hot,  malaria  might  be  expected.  The  high- 
tempeiature  conditions  favorable  to  the  extensive  development  of 
malaria  rarely  prevail  in  England,  nor  in  Flanders  and  the  north  of 
France.  Sporadic  cases  of  malaria  in  England  usually  occur  during  the 
late  summer,  that  is,  during  the  warmest  time  of  the  year.f  With 
reference  to  the  climatological  conditions  of  Flanders  and  the  north  of 
France,  it  is  said  in  the  article  referred  to  that  this  does  not  differ  very 
much,  and  that  a  cold  summer  in  one  usually  means  the  same  condition 
in  the  other.     As  regards  the  season  of  1915,  it  is  stated  that 

So  far  the  weather  in  England  has  been  this  year  quite  unsuitable  for  the 
development  of  the  malarial  parasite  in  the  mosqmto,  and  unless  a  very  much 
warmer  spell  occurs  in  August  and  September,  there  will  be  little  or  no  chance  of 
a  malarial  epidemic  or  outbreak  in  the  North  of  France.  Another  point  of 
interest  about  the  indigenous  malarial  cases  in  temperate  climates,  such  as  those 

•According  to  a  note  in  the  Scientific  American,  of  March  23,  1918,  "Malaria  was  once  common  in  cer- 
tain parts  of  England,  but  as  a  result  of  drainage  and  the  use  of  quinine,  it  was  completely  stamped  out,  not- 
withstanding the  fact  that  anopheline  mosquitoes  remain  in  the  country.  The  parasitic  cycle  was  broken,  and 
the  insect  was  no  longer  infected.  Now  comes  the  report  of  a  recrudescence  of  indigenous  malaria  in  Enlgand. 
According  to  a  circular  issued  by  the  Local  Government  Board,  many  men  have  contracted  the  disease  while 
fighting  on  the  western  fronts,  and  have  brought  it  home  with  them;  thus  they  serve  as  foci  of  infection  tor  the 
civilian  population.     Measures  are  being  taken  to  deal  with  the  carrier  mosquitoes." 

tin  The  Lancet,  of  October  20,  1917,  are  two  interesting  letters  on  Home-bred  Malaria  in  England,  the  first 
of  which  is  by  Sir  William  Osier,  who  refers  to  a  letter  by  Dr.  H.  B.  Newham  calling  attention  to  the  impor- 
tance of  distinguishing  recurrences  in  soldiers  from  infected  countries  and  the  true  home-bred  malaria  of  England. 
He  gives  expression  to  the  view  that  "In  temperate  climates  districts  from  which  malaria  has  disappeared  have 
not,  to  my  knowledge,  been  reinfected,"  and  that  therefore  "The  slight  risk,  then,  from  our  malarial  soldiers  in 
this  country  may  be  faced  cheerfully." 

90 


mentioned,  is  that  they  are  generally  of  the  benign  tertian  type,  a  form  of  malaria 
that  is  not  specially  dangerous  or  associated  with  a  high  death  rate.  The  North 
of  France  and  Flanders,  like  England,  are  too  cold  for  the  development  of  the 
malignant  types  of  the  disease. 

The  danger  at  the  time  was  therefore  rather  in  apprehension  of  an 
extensive  outbreak  among  the  British  troops  in  the  eastern  war  area, 
since  in  the  Dardanelles  the  conditions  as  regards  climate  and  temper- 
ature are  similar  to  those  found  in  Italy,  Greece  and  Cyprus.  The 
risk,  however,  was  recognized  to  be  "one  of  the  difficulties  with  which 
the  French  and  British  forces  have  to  contend,  and  the  accounts  which 
have  hitherto  reached  this  country  seem  to  show  that  there  is  little  or 
no  malaria  there  and  few  mosquitoes."  This  favorable  anticipation 
was,  however,  not  realized  in  subsequent  experience.  An  extensive 
outbreak  of  malaria  among  the  soldiers  of  Flanders  was  reported  upon 
in  admirable  detail  in  the  New  York  Sun  of  September  24,  1917,  on  the 
basis  of  a  description  by  the  Paris  Medical,  with  regard  to  which  it  is 
properly  pointed  out  that  the  outbreaks  "will  serve  to  remind  medical 
men  to  what  extent  soldiers  at  the  front  are  suffering  from  a  form  of  the 
disease  imported  from  Macedonia."*  In  continuation,  it  is  said  that 
"In  France  and  Flanders  the  ravages  of  malarial  disease  form  a  serious 
calamity.  Large  numbers  of  troops  are  rendered  inefficient  for  con- 
siderable periods  by  autumnal  fever,  as  it  is  called,  and  this  to  an  extent 
which  seriously  handicaps  the  military  position.  So  far  no  recent 
figures  as  to  the  amount  of  these  diseases  among  the  troops  have  been 
published,  but  it  is  well  known  that  the  amount  is  serious  and  that  in 
several  parts  of  the  country  large  hospitals  contain  for  the  first  time 
almost  no  patients  except  malarious  patients."!  According  to  an 
account  by  Dr.  Carnot,  in  the  Paris  Medical, 

The  patients  who  are  in  the  reserve  hospitals  of  the  Fifteenth  district  have  for 
the  most  part  a  continued  fever  with  stomachic  distress  and  malarial  parasites  in 
the  blood.  We  have  also  observed  a  number  of  cases  more  difficult  to  interpret, 
in  which  the  first  symptoms  of  malaria  appeared  in  France  a  long  time  after 
the  return  of  the  troops.  The  disease  is  now  marked  by  the  severity  of  its 
features  and  by  the  large  number  of  abnormal  symptoms. 

*R.  Blanchard  in  the  Bulletin  de  I'Academie  de  MSdecine,  Paris,  remarks  "That  the  English  troops  in  Mace- 
donia did  not  suffer  from  malaria  by  any  means  to  the  extent  of  the  French  troops."  This  result,  it  is  claimed, 
was  in  consequence  of  the  fact  that  the  British  military  government  considered  the  Macedonia  campaign  a 
"medical  war,"  and  placed  medical  matters  in  entire  charge  of  medical  officers,  with  highly  favorable  results 
for  the  health  of  the  troops. 

tFor  some  exceedingly  interesting  and  practically  useful  observations  on  the  past  occurrence  of  malaria  in 
northern  France  and  Flanders,  see  the  observations  on  the  "Geography  of  Malaria,"  by  John  Macculloch,  M. 
D.,  in  his  treatise  on  "Malaria:  An  Essay  on  the  Production  and  Propagation  of  this  Poison,"  etc.,  Philadelphia, 
1829,  p.  183,  et  seq.  During  recent  years  the  malaria  mortality  rate  of  Belgium  has  been  3.3  per  100,000  during 
1901-1905,  and  2.5  during  1906-1910.  During  the  decade  there  were  1,027  deaths  from  malarial  disease  in 
Belgium,  equivalent  to  considerably  more  than  100,000  cases. 

91 


In  proper  recognition  of  the  seriousness  of  the  situation,  not  only  from 
a  sanitary,  but  also  from  a  military  point  of  view,  the  French  Govern- 
ment during  1917  sent  a  permanent  malaria  commission  to  the  eastern 
front  to  take  up  the  question  of  antimalaria  prophylaxis.  The  de- 
cision to  do  so  had  been  arrived  at  in  January,  1917,  following  the 
studies  of  Drs.  Edmond  and  Sergent,  of  the  Pasteur  Institute  of  Algeria, 
who  were  sent  to  Macedonia  in  December,  1916. 

REPORT  OF  FRENCH  MALARIA  COMMISSION 

An  account  of  the  work  of  the  French  Anti-Malaria  Commission,  by 
R.  LeGroux,  was  published  in  the  Bulletin  of  the  Societe  de  Pathologic 
Exotique,  Paris,  1917,  a  translation  of  which,  by  Mrs.  Carolyn  G.  Van 
Dine,  has  made  the  following  observations  available  for  the  present 
purpose. 

The  Commission  was  under  the  direction  of  the  Chief  Medical 
Officer,  Dr.  Visbecq,  who  had  been  on  the  eastern  front  since  the  cam- 
paign of  the  Dardanelles,  and  who,  after  a  long  stay  in  Indo-China,  had 
become  thoroughly  familiar  with  questions  of  prophylaxis  and  organized 
methods  of  eradication  and  control.  Dr.  Visbecq  had  the  assistance  of 
Prof.  Laveran,  the  original  discoverer  of  the  malaria  parasite.  The 
Commission  consisted  of  four  administrative  officers,  twenty  physicians, 
and  one  hundred  men  qualified  to  administer  quinine,  and  three  hun- 
dred men  from  the  army  assigned  for  special  sanitary  purposes.  The 
area  under  observation  was  divided  into  districts,  and  a  complete  en- 
demic index  was  made  to  place  the  anopheline  prophylaxis  measures  on 
a  sound  basis  of  positive  knowledge  and  to  subsequently  control  the 
methods  of  quinine  prophylaxis  or  immunization  of  both  the  inhabitants 
and  the  soldiers;  in  other  words,  the  Commission  from  the  outset  con- 
centrated its  efforts  upon  both  anopheline  prophylaxis  and  quinine 
prophylaxis,  it  being  said  in  the  report  that  "In  these  two  lines,  the 
plans  of  the  Pasteur  Institute  of  Algeria,  those  of  Sir  Ronald  Ross  and 
those  of  Major-General  Gorgas  at  Panama  were  taken  into  account 
with  profit,  and  that  any  measure  having  given  good  results,  even  to 
the  smallest  degree,  had  not  been  overlooked.  In  the  first  rank  of 
these  measures,  the  Commission  puts  the  use  of  the  mosquito-bar  and 
the  daily  administration  of  quinine. 

FRENCH  METHODS  OF  PROPHYLAXIS 

Anopheline  prophylaxis,  it  is  explained  in  the  report,  was  being  car- 
ried out  by  an  active  warfare  against  the  larvae  of  the  mosquitoes,  and 


aot  by  extensive  drainage  undertakings  which  would  involve  a  whole 
region      The  destruction  of  breeding-places  by  means  of  the  use  ot  oil 
or  a  mixture,  according  to  circumstances,  was  directed  chiefly  to  the 
small  pools  near  the  camps  or  halting-places,  by  clearing  away  vegeta- 
tion  and  by  straightening  the  course  of  slow-moving  streams      All  ot  this 
work  was  chiefly  performed  by  the  three  hundred  members  of  the  samtary 
corps  specifically  entrusted  with  its  execution.     The  campaign  against 
the  adult  mosquito  was  in  the  main  confined  to  the  use  of  the  mos- 
quito-bar.    Some  of  these  bars  for  the  head  had  unfortunately  been 
found  to  be  of  improper  construction,  but  finally  a  model  recommended 
by  Prof.  Simpson  of  London  had  been  adopted.     A  model  protective 
tent  had  been  recommended  by  the  Pasteur  Institute,  being  of  light 
weight  and  water-proof,  but  nevertheless  presenting  inconveniences 
which  it  seemed  impossible  to  overcome,  particularly  as  regards  ettective 
ventilation  on  very  hot  nights.     As  a  slight  means  of  additional  pro- 
tection from  the  bites  of  mosquitoes,  the  use  of  ointments  contaimng 
essential  oils,  etc.,  was  recommended,  but  it  was  emphasized  that  the 
protection  was  only  temporary. 

The  work  of  the  mosquito  brigades,  as  developed  at  Panama,  is 
referred  to  by  the  Commission  as  having  been  adopted  at  the  outset,  as 
likely  to  prove  of  especial  advantage.*  The  men  were  therefore  in- 
structed in  the  methods  of  capturing  and  destroying  adult  mosquitoes 
in  the  interior  of  buildings,  including,  among  other  methods,  the  use  ot 
cresyl  vapors,   in  accordance  with  the  recommendations  of  J3ouet- 

Roubaud.  v       •         £  i.u 

The  quinine  prophylaxis  as  carried  out  under  the  direction  ot  the 
Commission  in  the  Eastern  Army  was  chiefly  by  doses  of  chloral-hydrate 
of  quinine,  provided  by  the  central  pharmacy  of  the  military  forces. 
The  doses  were  three  grains,  taken  daily  twice  or  three  times, 
according  to  circumstances.  There  seems  to  have  been  no  serious  diffi- 
culty in  inducing  the  adult  inhabitants  of  the  area  under  control  to  take 
quinine  in  this  form.  For  children  quinine  confections  were  made  use 
of  in  conformity  to  the  method  followed  by  the  general  government  of 
Algeria  In  accordance  with  the  recommendation  of  the  Pasteur 
Institute,  a  solution  of  quinine  in  oil  had  been  prepared,  containing  as 
a  base  twenty  centigrams  of  quinine  per  cubic  centimeter,  of  which  ten 
drops  were  considered  sufficient  for  the  prevention  of  malaria  in  nursing 
infants.     It  was  clearly  recognized  that  the  preventive  quimmzation 

•Of  practical  importance  on  this  aspect  of  the  subject  is  a  treatise  on  "Mosquito  Control  in  Panan^a."  by 
Joseph  A.  LePrince,  New  York,  1916. 


93 


of  the  troops  required  exceptional  care,  and  it  was  found  necessary 
to  watch  constantly  and  often  to  command  the  soldiers  under  supervision 
to  take  the  prescribed  doses  in  accordance  with  the  rules.  As  an  effec- 
tive control  measure  an  occasional  urinalysis  is  recommended,  with  the 
aid  of  the  Tanret  reaction. 

Not  satisfied  with  direct  measures  of  prophylaxis  the  Commission 
initiated  an  educational  propaganda  to  instruct  the  troops  of  the  danger 
of  mosquitoes  and  of  the  usefulness  of  quinine  when  taken  as  a  pre- 
ventive.* By  means  of  notices,  postcards  and  other  illustrations,  the 
soldiers  were  made  to  understand  the  role  of  the  mosquito  in  the  spread 
of  the  disease  and  the  importance  of  its  prevention  by  means  of  the 
taking  of  systematic  doses  of  quinine.  Among  others,  a  series  of  ten 
postcards,  illustrating  in  a  readily  comprehensive  form  the  essential 
facts  of  malaria  control,  cover  the  following  phases  of  the  question  in  its 
public  aspect: 

1  The  necessity  of  protecting  oneself  from  mosquitoes  if  one  would  live  long. 

2  The  advisability  of  using  protective  ointments  effectively. 

3  The  inadvisability  of  staying  near  to  water  for  the  purpose  of  fishing  or  for 
any  other  reason. 

4  The  advisability  of  sleeping  under  mosquito-bars  and  of  effectively  prevent- 
ing the  entrance  of  mosquitoes. 

5  The  duty  of  as  carefully  guarding  the  mosquito-bar  as  the  soldiers'  gun  and 
ammunition. 

6  The  duty  of  repairing  promptly  the  smallest  hole  in  the  mosquito-net. 

7  The  duty  of  taking  quinine  carefully  in  accordance  with  the  instructions. 

8  The  duty  of  taking  quinine  every  day  and  of  doing  so  willingly. 

9  The  advisability  of  pro^'ing  conclusively  that  the  quinine  has  been  taken 
daily  in  accordance  with  the  rules. 

10  The  obligation  of  taking  quinine  and  following  other  protective  suggestions 
against  malaria  as  a  duty  to  the  country  and  oneself. 

Aside  from  these  ten  cards  of  instruction,  notices  were  made  use  of 
emphasizing  among  others  the  following  essential  facts : 

1  To  keep  in  good  health  it  should  be  understood  that  there  are  certain 
mosquitoes  which  convey  the  parasite  of  malaria  by  their  bites. 

2  The  use  of  the  mosquito-bar  against  these  mosquitoes  will  make  it  possible 
to  rest  well  and  to  sleep  free  from  flies  and  mosquitoes.  It  should  therefore 
be  properly  taken  care  of,  and  all  necessary  precautions  must  be  used  to  make 
the  bar  effective. 

3  Quinine  is  an  effective  remedy  for  malaria  and  a  protection  against  the 
parasite,  since  the  soldiers  may  be  bitten  by  mosquitoes  in  spite  of  mosquito- 

*Some  of  the  French  Anti-Mosquito  Cartoons  have  been  reprinted  in  The  American  Journal  of  Public  Health, 
for  February,  1918.  They  were  communicated  by  Prof.  S.  M.  Gunn,  Associate  Director  of  the  Tuberculosis 
Commission  to  France. 

94 


bars.     Quinine  properly  taken  enters  the  blood  and  kills  the  parasite,  and  either 
frees  the  person  affected  from  the  disease  or  makes  the  fever  less  severe. 

4  Quinine  should  be  taken  every  day,  irrespective  of  the  duties  of  the  work 
or  other  circumstances,  as  an  effective  precaution  against  malarial  infection. 

That  these  efforts  have  been  in  a  measure  effective  is  apparently 
substantiated  by  the  following  brief  statement  in  The  British  Medical 
Journal,  of  November  17,  1917,  although  it  is  conceded  that  in  the 
French  army  in  Macedonia  "malaria  is  still  a  most  serious  cause  of 
disability,  regardless  of  an  observed  decline." 

It  is  reported  that  the  health  of  the  French  army  in  Macedonia  showed  a 
considerable  improvement  during  the  first  nine  months  of  this  year  as  compared 
with  last  year.  The  typhoid  admission-rate  was  1.38  per  1,000,  and  that  of 
dysentery  7.43.  Malaria  is  still  the  most  serious  cause  of  disability,  but  even 
here  there  has  been  a  notable  decline.  In  August  the  rate  was  23.8  in  1917,  as 
compared  with  39.16  in  1916,  and  in  September  it  was  29  in  1917,  as  compared 
with  74.6  in  1916.  It  is  further  to  be  noted  that  only  about  one-sixth  of  the 
admissions  in  September  were  new  cases.  The  improvement  is  attributed  to 
attention  to  the  sanitation  of  localities,  to  the  free  distribution  of  mosquito  nets, 
and  to  a  daily  dose  of  quinine,  the  taking  of  which  is  carefully  supervised. 

MODERN  CONCLUSIONS  BASED  UPON  WAR  EXPERIENCE 

The  most  recent  observations  on  malaria  in  its  relation  to  war  are 
a  group  of  five  leading  articles  in  Le  Progres  Medical,  for  December  8, 
1917,  briefly  reviewed  in  The  Medical  Record,  of  February  2,  1918.  It  is 
said  in  part  that 

Bernard  regards  malaria  as  second  in  importance  to  none  of  the  war  plagues. 
Not  only  was  it  of  the  highest  significance  in  the  warfare  at  the  Dardanelles, 
Salonica,  and  Macedonia,  but  from  these  foci  it  has  been  transplanted  throughout 
the  whole  of  France.  This  author  gives  a  complete  general  review  of  the  subject 
which  does  not  lend  itself  to  a  brief  epitomization.  An  extensive  bibliography 
is  appended.  Certain  paragraphs  are  of  special  interest.  Quinine  has  been 
used  heroically  and  cinchonism  has  ocemred  in  an  unprecedented  degree,  but 
the  general  symptoms  pale  into  insignificance  in  comparison  with  the  local  acci- 
dents which  foUow  intramuscular  injections  of  the  drug  into  the  buttocks. 
Large  and  deep  abscesses  and  extensive  sloughing  are  accidents  often  recorded 
and  illustrated.  The  distinction  between  primary  and  secondary  malaria  is 
carefully  maintained  throughout.  Owing  to  the  fact  that  quinine  tends  in 
time  to  lose  its  efficacy  we  are  confronted  by  a  special  type  of  quinine-foci  or 
quinine-resistant  paludics  to  whom  large  doses  and  intensive  treatment  may 
be  necessary  when  relapses  occur;  for  in  these  subjects  the  drug  will  no  longer 
prevent  relapses. 

Reference  is  made  to  the  work  of  Garin  and  Pasquier,  who  conclude 
from  a  study  of  hospitalization  that  "hospitals  for  malarial  subjects 

95 


should  have  an  altitude  of  not  less  than  1,000  meters,  in  order  to  pro- 
tect the  civilian  population."  A  second  paper  by  Bernard  is  referred 
to,  in  which  there  is  a  discussion  of  the  case  of  natives  presumably 
infected  by  returning  troops.  The  term  autochthonous  malaria  is 
made  use  of  to  indicate  a  recrudescence  of  old  native  malaria  in  the  war 
zone. 

The  serious  importance  of  malaria  in  its  relation  to  war  becomes  more 
evident  as  the  results  of  extensive  experience  in  the  war  area  are  made 
available  for  critical  consideration.  It  is  therefore  most  gratifying  to 
note  that  the  available  information  on  the  subject  and  its  special  ap- 
plication to  the  medical  service  of  the  war  have  been  summarized  in  a 
treatise  on  "Malaria:  Clinical  and  Haematological  Features  and 
Principles  of  Treatment,"  by  P.  Armand-Delille,  P.  Abrami,  G.  Pais- 
seau  and  Henri  Lemaire.  Preface  by  Prof.  Laveran,  Member  of  the 
Institute,  edited  by  Sir  Ronald  Ross,  K.  C.  B.,  F.  R.  S.,  LL.  D.,  D. 
Sc,  Leiut.-Col.,  R.  A.  M.  C.  This  work  is  based  on  the  writers'  observa- 
tions on  malaria  in  Macedonia  during  the  present  war  in  the  French 
Army  of  the  East.  It  is  emphasized  in  the  announcement  of  the  work 
that  "A  special  interest  attaches  to  these  observations  in  that  a  consider- 
able portion  of  their  patients  had  never  had  any  previous  attack.  The 
disease  proved  to  be  one  of  exceptional  gravity,  owing  to  the  exception- 
ally large  numbers  of  the  Anopheles  mosquitoes  and  the  malignant 
nature  of  the  parasite  (plasmodium  falciparum) ."  Fortunately,  it  is 
said,  "an  ample  supply  of  quinine  enabled  the  prophylactic  and  cura- 
tive treatment  to  be  better  organized  than  in  previous  colonial  cam- 
paigns, with  the  result  that,  though  the  incidence  of  malaria  among  the 
troops  was  high,  the  mortality  was  exceptionally  low." 

Of  additional  interest  in  this  connection  are  the  observations  on 
malaria  in  a  very  recent  treatise  on  "Typhoid  Fevers  and  Paratyphoid 
Fevers,"  by  Vincent  and  Muratet,  translated  by  J.  D.  Rolleston,  reading, 
in  part,  that 

In  hot  countries,  especially  along  the  Mediterranean  coast  (Salonica,  Greece, 
Turkey,  Syria,  Asia  Minor,  etc.)  malaria  often  assumes  a  continuous  type,  with 
digestive  disorders,  dry  and  coated  tongue,  bilious  vomiting,  diarrhea,  swollen 
and  tender  liver,  large  spleen,  headache,  insomnia,  etc.  The  febrile  state  is 
prolonged  in  patients  who  are  not  treated  with  quinine.  These  forms  of  so- 
called  tropical  malaria,  which  are  sometimes  very  severe,  are  often  confounded 
with  typhoid  and  paratyphoid  fevers. 

With  further  reference  to  differential  diagnosis,  or  serious  complica- 
tions, it  is  said  by  the  same  authors  that 

96 


In  hot  climates  and  in  the  East,  and  all  the  countries  along  the  shores  of  the 
Mediterranean  where  malaria,  papatacci  fever  (three-day  fever),  recurrent  fever 
and  Malta  fever  are  prevalent,  these  diseases  very  often  assume  a  typhoid 
disguise  which  may  mislead  the  doctor.  Laboratory  examination  will  lead  to 
the  adoption  of  the  prophylactic  measures  required  by  an  exact  diagnosis.  No 
rational  prophylaxis,  therefore,  can  be  carried  out  either  in  the  army  or  in  the 
civil  population  without  aid  from  the  laboratory. 

All  of  these  observations  and  much  additional  evidence  from  foreign 
sources  justify  the  serious  apprehension  regarding  malaria  as  a  factor 
not  only  in  military  efficiency  but  in  its  possible  reaction  upon  the  health 
of  the  population  at  large.  The  impoitance  of  the  disease  is,  of  course, 
clearly  recognized  by  the  military  authorities,  and  much  depends  upon  a 
thoroughly  effective  cooperation  on  the  part  of  the  civil  authorities  in 
charge  or  control  of  the  sanitary  conditions  of  areas  outside  of  the  military 
reservations.  The  experience  which  has  thus  far  been  had  seems  to 
convey  the  assurance  that  reasonably  adequate  precautions  have  been 
taken  to  safeguard  the  health  of  Northern  troops  in  Southern  canton- 
ments and  of  the  civil  population  more  or  less  in  contact  with  the  troops 
on  their  return  to  localities  where  the  anopheline  mosquitoes  are  the 
common  variety  and  therefore  properly  a  cause  of  apprehension  on  the 
part  of  the  public. 

MALARIA  PREVALENCE  IN  ARMY  CANTONMENTS 

The  statistics  of  the  Army  Medical  Department  for  the  period  of  the 
week  of  October  12,  1917,  to  the  week  of  January  25, 1918,  inclusive,  are 
presented  in  the  table  following,  with  regard  to  which  it,  however,  re- 
quires to  be  kept  in  mind  that  absolute  accuracy  is  not  claimed  therefor 
by  the  authorities,  in  view  of  the  extreme  difficulty  of  securing  complete 
returns,  especially  as  to  the  precise  mean  strength  of  the  men  exposed 
to  risk.  Their  main  object  is  to  furnish  general  information  as  to  the 
health  of  the  Army  and  to  give  to  the  public  at  large  a  reasonable  degree 
of  assurance  concerning  the  administrative  efficiency  of  the  Army 
Medical  Department.  Limited  for  the  present  purpose  exclusively 
to  malaria  morbidity,  the  statistics  indicate  that  at  the  commence- 
ment of  the  mobilization  malaria  was  a  fairly  perceptible  disease  factor, 
particularly  at  the  camps  established  for  the  National  Guard.  The 
value  of  the  table  lies  rather  in  its  future  use  as  a  reasonably  trust- 
worthy index  of  health  conditions  at  home  and  abroad  during  the 
malaria  season,  which  in  this  country  extends,  broadly  speaking,  from 
June  to  October. 

97 


MALARIA  MORBIDITY  OF  THE  UNITED  STATES  ARMY 

(Rate  per  1,000  Mean  Strength) 

p      I  National  National  American 

a™,,  Army  Guard  Expeditionary 


We<^kof 


Army 


(All  Camps)  (All  Camps)  Forcei 


Oct.    12,1917 4.8  5.8  14.2 

19 2.7  4.1  8.9 

26. 4.7  8.1  9.7 

Nov.    2 1.8  5.3  7.4  .. 

9 1.9  3.0  5.9 

16 1.6  2.4  5.0 

23 1.7  2.0  5.4  0.9 

30 0.2  5.7  1.8 

Dec.     7 0.5  1.0  1.1  2.0 

14 ...1.3  0.8  1.7 

21 1.0  0.6  2.1  0.3 

28 0.2  1.7 

Jan.     4, 1918 0.8  0.3  1.1 

11 1.7  0.2  1.9  0.8 

18 0.4  0.2  1.4  0.2 

25 0.8  0.3  1.5 

As  is  well  known  the  admission  rate  for  malarial  fever  in  the  United 
States  Army  has  been  gradually  reduced  from  extraordinary  propor- 
tions during  the  year  of  the  Spanish  American  War  (1898),  when  it  at- 
tained to  a  maximum  rate  of  694.64  per  1,000  to  a  minimum  of  24.75 
during  the  year  1913.  The  corresponding  reduction  in  the  non-eflfective 
rates  during  more  recent  years  was  from  4.46  per  1,000  during  1903 
to  0.53  during  1913.  Regarding  these  results  it  is  pointed  out 
in  a  discussion  of  the  Prophylaxis  of  Malaria  with  Special  Reference  to 
the  MiHtary  Service,  by  Charles  F.  Craig,  Captain,  Medical  Corps, 
United  States  Army,  that 

The  decrease  of  malaria  in  the  Army  has  been  brought  about  largely  by 
measures  directed  against  the  mosquitoes  transmitting  the  disease,  and  the  pro- 
tection of  man  from  the  bites  of  these  insects.  Quinine  prophylaxis  has  probably 
had  but  little  to  do  with  this  reduction,  as  the  use  of  this  method  has  been  very 
limited.  Neither  has  the  control  treatment  by  microscopic  examinations  of  the 
blood  and  the  treatment  of  "carriers"  and  latent  infections  operated  to  any 
extent  in  reducing  the  disease  in  the  Army,  as  these  methods  have  been  very 
little  used,  and  it  is  believed  that  had  these  methods  been  widely  employed  the 
reduction  of  malaria  would  have  been  much  more  marked  and  much  more -rapid 
than  it  has  been. 

98 


Craig  strongly  urges  the  adaptation  of  prophylactic  measures  to 
local  conditions,  based  upon  the  qualified  ascertainment  of  all  the 
factors  which  require  to  be  taken  into  account.  He  suggests  that  while 
"Under  some  conditions  we  may  be  able  to  practically  eradicate  mos- 
quitoes, under  others  this  measure  may  be  impossible,  and  quinine 
prophylaxis  will  have  to  be  substituted,  together  with  measures  for  the 
protection  of  man  from  the  bites  of  mosquitoes."  He  concludes  that 
"In  many,  if  not  most,  localities  the  best  results  will  be  secured  by  the 
combination  of  several  prophylactic  measures,"  and  he  is  not  at  all  in 
sympathy  "with  those  who  insist  that  either  upon  the  destruction  of 
mosquitoes  or  the  prophylactic  use  of  quinine  alone  we  must  depend  for 
success  in  the  prevention  of  the  malarial  fevers." 

MALARIA  IN  THE  UNITED  STATES  ARMY  MEDICAL 

EXPERIENCE 

In  conclusion,  the  following  summary  statement  of  the  Army  medical 
experience  with  reference  to  the  comparative  frequency  of  malaria  and 
typhoid  fever  in  the  United  States  Army  during  the  five  years  ending 
with  1915  will  prove  useful  as  a  trustworthy  basis  for  estimating  the 
comparative  minimum  hazard  of  malaria  as  a  factor  in  military  oper- 
ations. The  statistics  are  all  derived  from  the  annual  reports  of  the 
Surgeon-General  of  the  Army.* 

Among  the  oflScers  the  admission  rate  on  account  of  malaria  was  19.12 
per  1,000  of  mean  strength,  against  a  comparative  admission  rate  from 
typhoid  fever  of  only  0.23.  The  non-effective  rate  on  account  of  malaria 
was  0.61  per  1,000,  against  a  non-effective  rate  on  account  of  typhoid 
fever  of  only  0.10.  Among  American  troops  (enlisted  men)  the  malaria 
admission  rate  was  26.26  per  1,000  of  mean  strength,  against  a  typhoid 
fever  admission  rate  of  0.23.  For  white  enlisted  men  only  the  malaria 
admission  rate  was  27.09,  against  a  typhoid  fever  admission  rate  of  0.24. 
For  the  colored  troops  the  malaria  admission  rate  was  12.14  per  1,000, 
against  a  typhoid  fever  rate  of  only  0.09.  The  non-effective  rate  on 
account  of  malaria  was  0.60  per  1,000  for  enlisted  men,  against  0.05  on 
account  of  typhoid  fever.  For  white  troops  the  non-effective  rate  on 
account  of  malaria  was  0.62  per  1,000,  against  a  rate  of  0.05  for  typhoid 
fever;  while  for  the  colored  troops  the  non-effective  rate  on  account  of 
malaria  was  0.25  per  1,000,  against  0.01  on  account  of  typhoid  fever. 
For  the  continental  United  States  only,  exclusive  of  Alaska,  the  malaria 

•Only  the  original  statistics,  however,  have  been  derived  from  the  Annual  Reports  of  the  Surgeon-General. 
The  rates  for  the  quinquennial  period  are  original  calculations. 

99 


admission  rate  for  enlisted  men  was  12.17  per  1,000  of  mean  strength, 
against  0.24  for  typhoid  fever.  For  white  troops  only  the  rates  were 
12.49  for  malaria  and  0.24  for  typhoid  fever.  For  colored  troops  the 
rates  were  4.04  per  1,000  for  malaria  and  0.18  for  typhoid  fever. 

The  non-effective  rates  for  enlisted  men  of  the  continental  United 
States,  exclusive  of  Alaska,  were  0.27  per  1,000  mean  strength  for 
malaria,  against  0.06  for  typhoid  fever.  For  white  troops  only  the 
rates  were  0.27  and  0.06  per  1,000,  respectively;  and  for  colored  troops 
the  rates  were  0.08  and  0.02,  respectively,  per  1,000  of  mean  strength. 

For  enlisted  American  troops  in  Alaska  the  malaria  admission  rate 
was  2.11  per  1,000,  against  no  admissions  on  account  of  typhoid  fever; 
and  the  non-effective  rate  on  account  of  malaria  was  0.04. 

For  Hawaii  the  admission  rate  for  malaria  was  3.94  per  1,000,  against 
a  rate  of  0.17  for  typhoid  fever;  the  non-effective  rate  in  Hawaii  on  ac- 
count of  malaria  was  0.10  per  1,000,  against  0.02  for  typhoid  fever. 

For  the  Philippine  Islands  the  admission  rate  on  account  of  malaria 
was  95.03  per  1,000  against  0.29  for  typhoid  fever;  the  respective  non- 
effective rates  were  1.97  for  malaria  and  0.06  for  typhoid  fever.  For 
the  native  troops  in  the  Philippine  Islands  the  malaria  admission  rate 
was  191.03  per  1,000,  against  a  typhoid  fever  rate  of  0.57;  the  non- 
effective rates  were,  respectively,  3.41  for  malaria  and  0.10  for  typhoid 
fever. 

For  Porto- Rico  native  troops  the  admission  rate  on  account  of  malaria 
was  44.46  per  1,000,  against  0.32  for  typhoid  fever;  the  non-effective 
rates  were  respectively  0.73  for  malaria  and  0.03  for  typhoid  fever. 

The  army  experience  for  the  five-year  period,  therefore,  reemphasizes 
conclusions  drawn  from  general  experience  that  the  economic  impor- 
tance of  malaria  as  a  cause  of  disability  in  civil  or  military  service  de- 
mands decidedly  more  serious  and  qualified  consideration  than  has 
heretofore  been  the  case.  The  further  conclusion  may  be  advanced 
that  the  white  troops  in  the  continental  United  States  experience  a 
much  higher  malaria  admission  rate  and  non-effective  rate  than  the 
colored  troops,  but  that  they  suffer  most  from  malaria  in  the 
Philippine  Islands,  where,  however,  the  admission  and  non-effective 
rates  for  native  troops  are  about  twice  as  high  as  those  of  white  troops 
serving  under  more  or  less  identical  conditions. 

Finally,  the  evidence  is  conclusive  that  even  in  Alaska  and  Hawaii 
malaria  is  of  some  importance,  although  no  doubt  introduced  from 
localities  where  infected  anopheles  mosquitoes  are  the  cause  of 
the  disease.     In  Porto  Rico,  however,  the  native  troops  suffer  con- 

100 


siderably  from  malaria,  or,  approximately,  to  the  extent  of  four  times 
the  corresponding  admission  rate  among  the  white  troops  of  the  con- 
tinental United  States.*  Officers  of  the  United  States  Army  experience 
a  lower  admission  rate  than  enlisted  men  serving  at  home  and  abroad, 
but  practically  the  same  non-effective  rate  prevails  among  both  officers 
and  enlisted  men. 

The  experience  of  the  United  States  Army  with  reference  to  malaria 
during  a  period  of  peace,  when  adequate  attention  could  be  given  to  the 
most  effective  prophylactic  measures,  suggests  the  practical  value  of  a 
critical  examination  of  the  data  and  their  application  to  the  solution  of 
eradication  problems  at  Army  posts  and  barracks  at  which  the  disease 
is  known  to  prevail  ta  a  more  or  less  excessive  degree,  f  For,  after  all, 
in  malaria  it  is  never  a  question  of  the  mortality  or  the  morbidity  in  the 
aggregate  for  large  areas  or  states  or  countries,  but,  first  and  last,  in  its 
practical  application  it  is  a  local  question  demanding  highly  specialized 
consideration  of  all  local  factors  predisposing  to  malarial  disease  preva- 
lence of  more  or  less  serious  extent.  This  conclusion  applies  as  much 
to  military  operations  as  to  civil  life,  to  peace  conditions  as  well  as  to 
war  and  to  the  Army  as  much  as  to  the  population  at  large, 

*During  recent  years  the  mortality  from  malaria  has  been  considerably  on  the  increase  in  Porto  Rico.  The 
average  malaria  mortality  rate  per  100,000  of  population  by  single  years  during  the  last  five  years  has  been  as 
follows:  99.9  in  191S,  48.8  in  1913,  64.5  in  1914,  110.4  in  1915,  and  158.4  in  1916. 

fAn  exceptionally  valuable  report  on  "Extra-Cantonment  Zone  Sanitation,"  by  J.  A.  Watkins,  M.D.,U.  S. 
Public  Health  Service,  with  spec  iai  reference  to  conditions  at  Camp  Shelby,  near  Hatticsburg,  Miss.,  was  issued 
under  date  of  December  21,  1917  (Reprint  No.  443).  The  report  includes  a  full  descriptive  account  of  mosquito 
eradication  measures  incorporated  in  an  ordinance  passed  by  the  city  authorities  of  Hattiesburg,  Section  1  of 
which  reads  that  "It  shall  be  unlawful  to  have,  keep,  maintain,  cause  or  permit,  within  the  incorporated  limits  of 
Hattiesburg,  Miss.,  any  collection  of  standing  or  flowing  water  in  which  mosquitoes  breed  or  are  likely  to  breed, 
unless  such  collection  of  water  is  treated  so  as  to  effectively  prevent  such  breeding." 

The  enforcement  of  this  Section  is  provided  for  in  part  by  Section  5,  which  reads  that  "Should  the  person 
or  persons  responsible  for  conditions  giving  rise  to  the  breeding  of  mosquitoes  fail  or  refuse  to  take  necessary 
measures  to  prevent  the  same  within  three  days  after  notice  has  been  given  to  them,  the  health  officer  is  hereby 
authorized  to  do  so,  and  all  necessary  costs  incurred  by  him  for  this  purpose  shall  be  a  charge  against  the  prop- 
erty owner  or  other  person  offending  as  the  case  may  be." 

The  necessity  for  drastic  action  in  the  Hattiesburg  cantonment  district  is  made  evident  by  the  malaria 
morbidity  reports  for  Forrest  County,  indicative  of  a  normal  malaria  frequency  rate  of  from  80  to  100  per  1,000 
of  population. 


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